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Textbook of Natural Medicine - 2-volume set [5th Edition]
 0323523420, 9780323523424, 9780323523790

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Table of contents :
SECTION I: PHILOSOPHY OF NATURAL MEDICINE
1. Functional Medicine: A 21st Century Model of Patient Care and Medical Education
2. A Hierarchy of Healing: The Therapeutic Order
3. History of Naturopathic Medicine
4. History of Naturopathic Medicine Part 2
5. Philosophy of Naturopathic Medicine
6. Placebo and the Power to Heal
7. Positive Mental Attitude
SECTION II: SUPPLEMENTARY DIAGNOSTIC PROCEDURES
8. Apoptosis in Health and Disease
9. Bacterial Overgrowth of the Small Intestine Breath Test
10. Cell Signaling Analysis
11. Erythrocyte Sedimentation Rate
12. Fantus Test
13. Fatty Acid Profiling
14. Food Allergies
15. Genomics, Nutrigenomics, and the Promise of Personalized Medicine
16. Hair Mineral Analysis
17. Heidelberg pH Capsule Gastric Analysis
18. Immune Function Assessment
19. Intestinal Permeability Assessment
20. Laboratory Tests for the Determination of Vitamin Status
21. Lactose Intolerance Testing
22. Metal Toxicity: Assessment of Exposure and Retention
23. Mineral Status Evaluation
24. Mold Exposure Assessment
25. Non Metallic Toxic Chemical Assessment
26. Oral Manifestations of Nutritional Status
27. Rapid Dark Adaptation Test
28. Stool Analysis
29. Urinary Organic Acids Profiling for Assessment of Functional Nutrient Deficiencies, Gut Dysbiosis, and Toxicity
30. Urinary Porphyrins for the Detection of Heavy Metal and Toxic Chemical Exposure
31. Urine Indican Test (Obermeyer Test)
SECTION III: THERAPEUTIC MODALITIES
32. Acupuncture
33. Ayurveda: The Science of Life and Mother of the Healing Arts
34. Botanical Medicine – A Modern Perspective
35. Environmental Medicine
36. The Exercise Prescription
37. Fasting
38. Glandular Therapy
39. Homeopathy
40. Hydrotherapy
41. Manipulation
42. Nonpharmacological Control of Pain
43. Nontransfusion Significance of ABO and ABO-Associated Polymorphisms
44. Nutritional Medicine
45. Peat Therapeutics and Balneotherapy
46. Rotation Diet: A Diagnostic and Therapeutic Tool
47. Soft Tissue Manipulation: Diagnostic and Therapeutic Potential
48. Spirituality and Healing
49. Unani Medicine
SECTION IV: PHARMACOLOGY OF NATURAL MEDICINES
50. Allium cepa (Onion)
51. Allium sativum (Garlic)
52. Aloe vera (Cape Aloe)
53. Angelica Species
54. Artemisia absinthium (Wormwood)
55. Artemisia annua (Sweet Wormwood)
56. Bee Products – Pollen, Propolis, and Royal Jelly
57. Beta-carotene and Related Carotenoids
58. Boron
59. Bromelain
60. Camellia sinensis (Green Tea)
61. Cannabis sativa, THC, and Cannabidiols
62. Capsicum frutescens (Cayenne Pepper)
63. Carnitine
64. Centella asiatica (Gotu Kola)
65. Chinese Prepared Medicines
66. Cimicifuga racemosa (Black Cohosh) John Nowicki and Michael T. Murray
67. Citicoline (CDP-Choline)
68. Coenzyme Q10
69. Coleus forskohlii
70. Commiphora mukul (Mukul Myrhh Tree)
71. Crataegus oxyacantha (Hawthorn)
72. Croton lechleri (Dragon's Blood)
73. Curcuma longa (Turmeric)
74. Dehydroepiandrosterone (DHEA)
75. Echinacea Species (Narrow-Leafed Purple Coneflower)
76. Eleutherococcus senticosus (Siberian Ginseng)
77. Ephedra Species
78. Epilobium Species (Fireweed)
79. Fatty Acid Metabolism
80. Fish Oils and Omega-3 Fatty Acids
81. Flavonoids – Quercetin, Citrus Flavonoids, and Hydroxyethylrutosides
82. Ginkgo biloba (Ginkgo Tree)
83. Glucosamine
84. Glutamine
85. Glycyrrhiza glabra (Licorice)
86. Hydrastis canadensis (Goldenseal) and Other Berberine-Containing Botanicals
87. 5-Hydroxytryptophan
88. Hypericum perforatum (St John's Wort)
89. Lobelia inflata (Indian Tobacco)
90. Medicinal Mushroom
91. Melaleuca alternifolia (Tea Tree)
92. Melatonin
93. Melissa officinalis (Lemon Balm)
94. Mentha piperita (Peppermint)
95. Microbial Enzyme Therapy
96. Natural Medicines Quality Control
97. Naturally Occurring Antioxidants
98. Opuntia Species (Prickly Pear)
99. Panax ginseng (Korean Ginseng)
100. Pancreatic Enzymes
101. Phage Therapy: Bacteriophages as Natural, Self-limiting Antibiotics
102. Phosphatidylserine
103. Piper methisticum (Kava)
104. Prebiotics
105. Probiotics
106. Procyanidolic Oligomers
107. Pygeum africanum (Bitter Almond)
108. Pyroloquinoline quinone (PQQ)
109. Ruscus aculeatus (Butcher's Broom)
110. SAMe (S-Adenosylmethionine)
111. Sarsparilla Species
112. Serenoa repens (Saw Palmetto)
113. Silybum marianum (Milk Thistle)
114. Soy Isoflavones and Other Constituents
115. Tabebuia avellanedae (LaPacho, Pau D'Arco, Ipe Roxo)
116. Tanacetum parthenium (Feverfew)
117. Taraxacum officinale (Dandelion)
118. Taxus brevifolia (Pacific Yew)
119. Urtica dioica (Stinging Nettle)
120. Uva ursi (Bearberry)
121. Vaccinium macrocarpon (Cranberry)
122. Vaccinium myrtillus (Bilberry)
123. Valeriana officinalis (Valerian)
124. Viscum album (European Mistletoe)
125. Vitamin A
126. Vitamin K
127. Vitamin Toxicities and Therapeutic Monitoring
128. Vitex agnus castus (Chaste Tree)
129. Water: The Most Basic Nutrient and Therapeutic Agent
130. Zingiber officinale (Ginger)
SECTION V: SYNDROMES AND SPECIAL TOPICS
131. Cancer – Key Considerations in Prevention
132. Dietary Fiber
133. Digestive Support
134. Homocysteine Metabolism: Nutritional Modulation and Impact on Health and Disease
135. Hyperventilation Syndrome/Breathing Pattern Disorders
136. Immune System Support
137. Let the Data Speak
138. Mycotoxins
139. Sports Nutrition
140. Stress Management
SECTION VI: SPECIFIC HEALTH PROBLEMS
141. Acne Vulgaris and Acne Conglobata
142. Affective Disorders
143. Alcohol Dependence
144. Alzheimer's Disease
145. Anemia
146. Angina
147. Aphthous Stomatitis
148. Asthma
149. Atherosclerosis
150. Atopic Dermatitis (Eczema)
151. Attention Deficit Hyperactivity Disorder in Children
152. Autism
153. Bacterial Sinusitis
154. Benign Prostatic Hyperplasia
155. Bronchitis and Pneumonia
156. Carpal Tunnel Syndrome
157. Celiac Disease
158. Cervical Dysplasia
159. Chronic Candidiasis
160. Chronic Fatigue Syndrome
161. Congestive Heart Failure
162. Constipation
163. Cystitis, Interstitial Cystitis/Painful Bladder Syndrome, and O

Citation preview

TEXTBOOK OF

Natural Medicine FIFTH EDITION EDITED BY

Joseph E. Pizzorno, ND

Editor in Chief, Integrative Medicine: A Clinician’s Journal, Eagan, Minnesota; President Emeritus, Bastyr University, Kenmore, Washington; Chair, Science Board, Bioclinical Naturals, Burnaby, British Columbia

Michael T. Murray, ND

President and CEO, Dr. Murray Natural Living, Inc., Scottsdale, Arizona; Chief Science Officer, Enzymedica, Venice, Florida

Elsevier 3251 Riverport Lane St. Louis, Missouri 63043 TEXTBOOK OF NATURAL MEDICINE, FIFTH EDITION Copyright © 2021 by Elsevier, Inc. All rights reserved. 

ISBN: 978-0-323-52342-4 Volume 1: 978-0-323-52326-4 Volume 2: 978-0-323-52325-7

No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher. Details on how to seek permission, further information about the Publisher’s permissions policies and our arrangements with organizations such as the Copyright Clearance Center and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions. This book and the individual contributions contained in it are protected under copyright by the Publisher (other than as may be noted herein).

Notice Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds or experiments described herein. Because of rapid advances in the medical sciences, in particular, independent verification of diagnoses and drug dosages should be made. To the fullest extent of the law, no responsibility is assumed by Elsevier, authors, editors or contributors for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein. Previous editions copyrighted 2013, 2006, 1999, and 1993. International Standard Book Number: 978-0-323-52342-4

Senior Content Strategist: Linda Woodard Senior Content Development Specialist: Rebecca Leenhouts Publishing Services Manager: Julie Eddy Book Production Specialist: Clay S. Broeker Design Direction: Margaret Reid Printed in China Last digit is the print number: 9 8 7 6 5 4 3 2 1

To Dr. John Bastyr and all the natural healers of the past and future who bring the “healing power of nature” to all the people of the world. Dr. Bastyr, the namesake for Bastyr University, exemplified the ideal physician/healer/teacher we endeavor to become in our professional lives. We pass on a few of his words of wisdom to all who strive to provide the best of health care and healing: “Always touch your patients—let them know you care,” and “Always read at least one research article or learn a new remedy before you retire at night.”

CONTRIBUTORS Kathy Abascal, BS, JD, RH(AHG)

Warren M. Brown, ND

Terry M. Elder, DC

Vashon, Washington

Clinical Science Liaison Medical Affairs Genova Diagnostics Asheville, North Carolina

Instructor Clinical Sciences National University of Health Sciences Lombard, Illinois

Michael J. Chapman, ND

Geovanni Espinosa, ND, LAc, IFMCP, CNS

Yaser Abdelhamid, ND, LAc, MS, BS, BA Licensed Acupuncturist Center for Integrative and Lifestyle Medicine Cleveland Clinic Cleveland, Ohio

Zemphira Alavidze, PhD

Medical Education Specialist Medical Affairs Genova Diagnostics Asheville, North Carolina

Lise Alschuler, ND

Alan G. Christianson, NMD

Professor of Clinical Medicine Assistant Director, and Fellowship in Integrative Medicine Program of Integrative Medicine University of Arizona Tucson, Arizona

President and Executive Integrative Health Scottsdale, Arizona

Anthony J. Cichoke Jr., BS, BS, MA, MA, PhD, DC, DACBN Portland, Oregon

Sidney MacDonald Baker, MD Independent Retirement Home Sag Harbor, New York

George W. Cody, JD, MA Consulting Historian Edmonds, Washington

Stephen Barrie, ND, PhD Senior Executive Viome Bellevue, Washington

David Barry, BS, BAppSci (Hons), DC, ND Clinical Research Coordinator Emeritus Research Camberwell, Victoria, Australia Senior Lecturer, Naturopathy Endeavour College of Natural Health Melbourne, Victoria, Australia

Kevin L. Conroy, ND Owner Private Practice Port Angeles Natural Health Port Angeles, West Virginia

Peter J. D’Adamo, ND, MIFHI Professor Clinical Sciences University of Bridgeport College of Naturopathic Medicine Coder/Developer Opus 23 & SWAMI

Peter W. Bennett, ND

Jade Dandy, ND, MSiMR

Clinic Director Patient Care Meditrine Naturopathic Medical Clinic Langley, British Columbia, Canada

The Healing Hut Clinic Eagle, Idaho National University of Natural Medicine Portland, Oregon

Faculty Clinical Assistant Professor NYU Langone Health, Urology Educator Institute for Functional Medicine New York, New York

Ralph Esposito, ND, LAc Adjunct Faculty New York University New York, New York

Susan Ann Gaylord, PhD Director, Program on Integrative Medicine Physical Medicine and Rehabilitation University of North Carolina (UNC) Chapel Hill, North Carolina Associate Professor Physical Medicine and Rehabilitation UNC School of Medicine Chapel Hill, North Carolina

Alan Goldhamer, DC Director Residential Health Education Program TrueNorth Health Center Santa Rosa, California Chairman of the Board Research/Education TrueNorth Health Foundation Santa Rosa, California

Andrea Gruszecki, ND Science Support Specialist Meridian Valley Laboratory Tukwilla, Washington

Bob G. Blasdel, PhD Research Director Vésale Pharma Noville-sur-Mehaigne, Belgium

Patricia M. Devers, DO

Jason A. Hawrelak, ND, BNat(Hons), PhD

Medical Education Specialist Department of Medical Affairs Genova Diagnostics, Inc.

Senior Lecturer in Complementary and Alternative Medicines College of Health & Medicine University of Tasmania Hobart, Tasmania, Australia Visiting Research Fellow Australian Research Centre for Complementary and Integrative Medicine University of Technology Sydney Sydney, New South Wales, Australia

Peter B. Bongiorno, ND, MSAc, LAc Co-Medical Director Naturopathic Medicine Inner Source Health New York, New York

Jamie Doughty, BSc, ND Medical Director Naturopathic Medicine Tummy Temple Olympia, Washington

Rachelle S. Bradley, ND Private Practice Heartland Naturopathic Clinic Omaha, Nebraska

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William Eisner, BSc Pediatrics/Cardiology Duke University Durham, North Carolina

CONTRIBUTORS

Bethany Montgomery Hays, MD

Robert Kachko, ND, LAc

Pina LoGiudice, ND, LAc

Assistant Clinical Professor Maine Medical Center Dept Ob/Gyn Tufts University School of Medicine Portland, Maine

Practitioner Naturopathic Medicine Inner Source Health New York, New York Chief Executive Officer TribeRx New York, New York

Co-Owner Innersource Natural Health and Acupuncture, PC Huntington, New York

Leah Hechtman, MSci (RHHG), BHSc (Nat), ND PhD Candidate Department of Obstetrics, Gynaecology and Neonatology | Faculty of Medicine University of Sydney Sydney, New South Wales, Australia President National Herbalists Association of Australia Sydney, New South Wales, Australia Director and Clinician The Natural Health and Fertility Centre Sydney, New South Wales, Australia

Joseph Katzinger, ND Science Director SaluGenecists Seattle, Washington

Naomi Hoyle, MD Eliava Phage Therapy Center Phage Therapy Eliava Foundation Tbilisi, Georgia

Corene Humphreys, ND, BHSc, Dip Med Herb, Dip Hom, QTA Director Nutritional Medicine

Mary James, ND Medical Editor Naturopathic Doctor News & Review Scottsdale, Arizona Expert Panel Member Women’s Health Network Portland, Maine

Chief Science Officer and Director of Quality BrainMD Health Amen Clinics Costa Mesa, California

Richard J. Kitaeff, MA, ND, Dip Ac, LAc Doctor and Clinic Director New Health Medical Center Edmonds, Washington Staff Acupuncturist Neurology Northwest Hospital Seattle, Washington Clinical Affiliate Faculty Acupuncture and Oriental Medicine Bastyr University Seattle, Washington

Cheryl Kos, ND Developer Content Personalized Medicine Lifestyle Institute Bainbridge Island, Washington

Executive Director of Medical Education Medical Education Institute for Functional Medicine Federal Way, Washington

Independent Researcher Kenmore, Washington

Helen (Verhesen) Messier Founder & Chief Medical Officer Medical Intelligence Learning Labs, Inc. San Jose, California

Steven C. Milkis, ND Owner Green Lake Natural Medicine Seattle, Washington

Gaetano Morello, ND Clinician, Complex Chronic Disease Program BC Women’s Hospital Vancouver, Canada

Gerard E. Mullin, MD Associate Professor of Medicine Gastroenterology and Hepatology Johns Hopkins School of Medicine Baltimore, Maryland

Stephen P. Myers, ND, BMed PhD

Thomas A. Kruzel, MT, ND

Professor and Director NatMed Research Unit Southern Cross University New South Wales, Australia

Rockwood Natural Medicine Clinic Scottsdale, Arizona

Toshia R. Myers, BS, MA, MPhil, PhD

Sarah Kuhl, MD, PhD

Ordained Minister United Church of Christ

Physician Medicine VA Northern California Martinez, California

Wayne Jonas, MD

Elizabeth Kutter, BS, PhD

Executive Director Samueli Integrative Health Programs H&S Ventures Alexandria, Virginia

Faculty Emeritas Bacteriophage Lab The Evergreen State College Olympia, Washington

Maeba Jonas, MDiv

Robert Luby, MD

Tennille Marx, ND, CFS Parris M. Kidd, BSc, PhD

Wendy Hodsdon, ND Adjunct Faculty Department of Graduate Studies National University of Natural Medicine Portland, Oregon Adjunct Faculty Maryland University of Integrative Health Laurel, Maryland

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Michael Alexander Lane, MD Assistant Professor Department of Neurology Oregon Health and Sciences University Portland, Oregon

Research Director Research TrueNorth Health Foundation Santa Rosa, California

Tara Nayak, ND Naturopathic Physician Philadelphia, Pennsylvania

Mark Harrison Nolting, ND, EAMP Senior Medical Director Physical Medicine TivityHealth Chandler, Arizona Medical Director Edmonds Wellness Clinic Edmonds, Washington

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CONTRIBUTORS

John Nowicki, ND

David Quig, PhD

Michael Scott, ND, MSA

Medical Writer, Research Associate Medical Research Team Integrative Medicine Advisors, LLC Seattle, Washington

Vice President Scientific Support Doctor’s Data, Inc. St. Charles, Illinois

Doctor Private Practice UrbanHealthWorks Boulder, Colorado

Brian Orr, BA, BS, ND

John C. Reed, MD, MDiv

Tracey Seipel, FANPA, ABC

Owner Country Doc: Integrative Medical Specialty Seattle, Washington

Founding VP and Fellow of the American Academy of Medical Acupuncture Fellow of the Osteopathic Cranial Academy Diplomate of the American Board of Family Medicine Diplomate of the American Board of Integrative Medicine Founding Member, American Holistic Medical Association

Fellow of the Australian Naturopathic Practitioners Association American Botanical Council Queensland, Australia

Ron Reichert, BA, ND Naturopathic Physician North Vancouver, Canada

Ann Shippy, MD

Kristaps Paddock, ND Medical Director Charm City Natural Health Baltimore, Maryland

William Shaw, PhD President Great Planes Laboratory Kansas City, Missouri

Cristiana I. Paul, MS Nutrition Independent Research Consultant Nutritional Biochemistry Research Cristiana Paul Consulting Los Angeles, California

Functional Medicine Physician Environmental Health Expert Austin, Texas

Corey Resnick, ND Nicole Pierce, ND Co-creator The Vervain Collective Garden City, Idaho

Lara Pizzorno, MAR, MA, LMT Senior Medical Writer and Editor Writing and Editorial Staff Integrative Medicine Advisors, LLC Seattle, Washington Senior Medical Editor SaluGenecists, Inc. Seattle, Washington

Terry Arden Pollock, BS, MS Medical Education Specialist Medical Affairs Genova Diagnostics Asheville, North Carolina

Dirk W. Powell, BS, ND Adjunct Professor Naturopathic Medicine Bastyr University Kent, Washington

President Integrative Health and Nutrition, Inc. Lake Oswego, Oregon Member Medical Advisory Board Integrative Therapeutics Green Bay, Wisconsin

Deceased

Clinical Assistant Professor Rusk Rehabilitation New York University Langone Medical Center New York, New York Adjunct Professor Health Sciences Touro College New York, New York

Elaine Roe, MD

Anna Sitkoff, BS, ND

Physician, Hall Health Center University of Washington Seattle, Washington

Herbalist Naturopathic Medicine Bastyr University Seattle, Washington

Sally J. Rockwell, PhD, CCN

Robert A. Ronzio, PhD Executive Director Research and Educational Services Insight Learning Institute Austin, Texas

Angela Sadlon, ND All Encompassing Healthcare Centralia, Washington

Lahnor Powell, ND, MPH

Alexander G. Schauss, PhD

Medical Education Specialist Department of Medical Affairs Genova Diagnostics Duluth, Georgia

Senior Director of Research Natural and Medicinal Products Research AIBMR Life Sciences, Inc. Seattle, Washington Research Associate Bio5 Institute University of Arizona Tucson, Arizona Research Associate Geosciences University of Arizona Tucson, Arizona

Matt Pratt-Hyatt, PhD Associate Lab Director The Great Plains Laboratory, Inc. Lenexa, Kansas

Barbara Siminovich-Blok, ND, LAc

Pamela Snider, ND Executive and Senior Editor Foundations of Naturopathic Medicine Project Foundations of Naturopathic Medicine Institute Snoqualmie, Washington Associate Professor College of Naturopathic Medicine National University of Natural Medicine Portland, Oregon Faculty School of Naturopathic Medicine Bastyr University Kenmore, Washington Co-Founder Integrative Health Policy Consortium Conifer, Washington

CONTRIBUTORS

Virender Sodhi, MD (Ayurveda), ND

Sherry Torkos, BSc, Phm, RPh

Vijayshree Yadav, MD, MCR, FAAN

Founder Ayurvedic Naturopathic Medical Clinic Bellevue, Washington Founder and Chief Executive Officer Ayush Herbs Redmond, Washington

Pharmacist and Author Fort Erie, Ontario, Canada

Associate Professor Neurology Oregon Health & Science University Portland, Oregon

Nick Soloway, LMT, DC, LAc Private Practice Helena, Montana

Jessica Tran, ND, MBA Private Practice Environmental Medicine Wellness Integrative Naturopathic Center, Inc. Irvine, California

Michael Traub, ND, DHANP, FABNO Lindsey Stuart, MS, CNM

Alumni Naturopathic Medicine National University of Natural Medicine Portland, Oregon

Medical Director Dermatology Lokahi Health Center Kailua Kona, Hawaii Clinical Professor of Graduate Medical Education Postgraduate Education Bastyr University Seattle, Washington

Mollie Parker Szybala, ND, MPH

Roy Upton, RH

Doctor Naturopathic Medicine Sun Valley Natural Medicine Ketchum, Idaho

President American Herbal Pharmacopoeia Scotts Valley, California

Certified Nurse Midwife Boulder, Colorado

Cory Szybala, ND

Venessa Wahler, ND Jade Teta, ND Owner/Founder/CEO Metabolic Effect Inc. Greensboro/Winston-Salem, North Carolina

Lead ND Naturopathic Medicine Tummy Temple Seattle, Washington

Keoni Teta, ND

Edward C. Wallace, ND, DC

Owner The Naturopathic Health Clinic of North Carolina Greensboro/Winston-Salem, North Carolina

Medical Education Specialist Medical Affairs Genova Diagnostics Asheville, North Carolina

Brice Thompson, ND, MS

Terry Willard, CIH, PhD

Postdoctoral Scholar Department of Pharmaceutics University of Washington Seattle, Washington

Founder Wild Rose College of Natural Healing Calgary, Canada

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Eric L. Yarnell, ND, RH(AHG) Professor Botanical Medicine Bastyr University Kenmore, Washington Chief Medical Officer Northwest Naturopathic Urology Seattle, Washington

Jared Zeff, ND Naturopathic Physician Salmon Creek Clinic Portland, Oregon

Heather Zwickey, PhD Professor School of Graduate Studies National University of Natural Medicine Portland, Oregon Adjunct Faculty Neurology Oregon Health and Science University Portland, Oregon Human Nutrition and Functional Medicine University of Western States Portland, Oregon

P R E FA C E This fifth edition of the Textbook of Natural Medicine (which has now been in publication since 1985) brings several new features and changes to our structure and format. We are especially excited that we are in full color for the first time, including images and figures. These dramatically improve our ability to present, in a more understandable and visually interesting way, the key concepts of and insights into the underlying causes of dysfunction and disease. We are also delighted that with all the new chapters and graphics, Elsevier has moved us back to the two-volume format. To better fit the content into two logical volumes, we changed the order (and some of the titles) of the sections. Syndromes and Special Topics moved to Section V because these fit better in Volume 2 with Section VI, Diseases. Pharmacology of Natural Medicines moved to Section IV because this fits better with Volume 1. As usual, we offer many new chapters, and we think the new chapter on sarcopenia is of particular importance. In addition to new chapters, some chapters have been renamed for better consistency, and some have been moved to sections that we felt were more appropriate. To

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facilitate utilization, the sections are now color coded, and we have provided alphabetical tabs to help readers in searching for specific diseases. Closely related diseases have been placed in a single chapter―for example, depression, dysthymia, manic phase, and seasonal affective disorder are all located in the chapter on affective disorders chapter―so becoming familiar with these groupings is essential for finding specific diseases. There are now 14 appendices that provide additional resources for the clinician. We worked with authors to make their writing more succinct and eliminate unnecessary content. We also reduced the length of Section VI by removing duplication of content from Section V in the therapeutics portion of the chapters. We hope you will be as pleased with the latest edition as we are. Due to the substantial increase in pages this edition, to keep down costs we had to move all of the approximately 20,000 references to the online version. Joseph E. Pizzorno Michael T. Murray

ACKNOWLED GMENTS We would like to thank Inta Ozols, the original commissioning editor, our executive assistant Lavelle Brown (who so effectively organized and managed all the authors and chapters), and the dedicated staff at Elsevier (Kristin Wilhelm, Linda Woodard, Laurie Gower, Becky Leenhouts, Jeff Patterson, Julie Eddy, Clay Broeker, Margaret Reid, Deanna Sorenson, and Allison Kieffer) for their excellent work in making this the best edition ever.

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SECTION

1

Philosophy of Natural ­Medicine One of the key features of the various schools of natural medicine that differentiates them from conventional medicine is their strong philosophical foundation. The basic philosophical premise of naturopathic medicine, for example, is that there is an inherent healing power in nature and in every human being. We believe that a primary role of the physician is to “remove the blocks to cure” and enhance this innate healing power within his or her patients. In many ways, this was the most difficult section of the textbook to write because, before this textbook, no comprehensive history of the social, political, and philosophical development of naturopathic medicine had ever been written. Even in the halcyon years of the 1920s and 1930s, the profession was never able to agree upon a concise philosophy. This situation has now changed. In this section, we provide well-documented chapters detailing the roots of American natural medicine. After a century of maturation, the naturopathic profession has now widely agreed to a comprehensive definition, set of principles, and system of case analysis that provide a systematic guide for the application of these concepts in a clinical setting. The seven fundamental principles of naturopathic medicine are as follows: The healing power of nature (vis medicatrix naturae) First, do no harm (primum non nocere) Find the cause (tolle causam) Treat the whole person Preventive medicine Wellness Doctor as teacher These principles translate into the following questions the practitioner applies when analyzing a case: • What is the first cause; what is contributing now? • How is the body trying to heal itself? • What is the minimum level of intervention needed to facilitate the self-healing process? • What are the patient’s underlying functional weaknesses? • What education does the patient need to understand why he or she is sick and how to become healthier? • How does the patient’s physical disease relate to his or her psychological and spiritual health? We have further expanded on the philosophical basis of naturopathic medicine by having these concepts addressed by several authors whose backgrounds allow each of them a unique and, we believe, complementary insight into some of the fundamental questions of the goals of health care. Although the dominant school of medicine has essentially ignored these issues, we believe that the true physician cannot function without a sound philosophical basis to guide his or her actions. Without more than a superficial understanding of health and disease, the physician is more likely to function as a technician, temporarily alleviating symptoms while allowing the real disease to progress past the point of recovery. The huge and increasing burden of chronic disease in all age groups clearly validates the predictions of the founders of naturopathic medicine that primarily treating symptoms, while not addressing causes, results in increased chronic disease.

1

1 Functional Medicine: A 21st-Century Model of Patient Care and Medical Education Robert Luby, MD, and Leo Galland*, AB, MD OUTLINE What Is Functional Medicine?, 2 Principles, 2 Lifestyle and Environmental Factors, 4 Fundamental Physiological Processes, 4 Core Clinical Imbalances, 4 Antecedents, Triggers, and Mediators, 5 Antecedents and the Origins of Illness, 5

Triggers and the Provocation of Illness, 5 Mediators and the Formation of Illness, 6 Constructing the Model, 6 Assessment, 6 The Functional Medicine Matrix Model, 6 The Healing Partnership, 8 Integration of Care, 10

In this chapter, the basic principles, constructs, and methodology of functional medicine are reviewed. It is not the purpose of this chapter to recapitulate the range and depth of the science underlying functional medicine; books and monographs covering that material in great detail are already available for the interested clinician and for use in health professional schools (see Bibliography at the end of the chapter). The purpose is to describe how functional medicine is organized to deliver personalized systems medicine and is equipped to respond to the challenge of treating complex chronic disease more effectively.

has not really produced an efficient method for identifying and assessing changes in basic physiological processes that produce symptoms of increasing duration, intensity, and frequency, although it is known that such alterations in function often represent the first signs of conditions that, at a later stage, become pathophysiologically definable diseases. By broadening the use of functional to encompass this view, functional medicine becomes the science and art of detecting and reversing alterations in function that clearly move a patient toward chronic disease over the course of a lifetime. One way to conceptualize where functional medicine falls in the continuum of health and health care is to examine the functional medicine “tree.” In its approach to complex chronic disease, functional medicine encompasses the whole domain represented by the graphic shown in Fig. 1.1, but it first addresses the patient’s core clinical imbalances (found in the functional physiological organizing systems); the fundamental lifestyle factors that contribute to chronic disease; and the antecedents, triggers, and mediators that initiate and maintain the disease state. Diagnosis, of course, is part of the functional medicine model, but the emphasis is on understanding and improving the functional core of the human being as the starting point for intervention. Functional medicine clinicians focus on restoring balance and improved function in the dysregulated systems by strengthening the fundamental physiological processes that underlie them and by adjusting the environmental and lifestyle inputs that nurture or impair them. This approach leads to therapies that focus on restoring health and function, rather than simply controlling signs and symptoms. 

WHAT IS FUNCTIONAL MEDICINE? Functional medicine encompasses a dynamic approach to assessing, preventing, and treating complex chronic disease. It helps clinicians of all disciplines identify and ameliorate dysfunctions in the physiology and biochemistry of the human body as a primary method of improving patient health. This model of practice emphasizes that chronic disease is almost always preceded by a period of declining function in one or more of the body’s physiological organizing systems. Returning patients to health requires reversing (or substantially improving) the specific dysfunctions that contributed to the disease state. Those dysfunctions are, for each of us, the result of lifelong interactions among diet, environment, lifestyle choices, and genetic predispositions. Each patient, therefore, represents a unique, complex, and interwoven set of influences on intrinsic functionality that, over time, set the stage for the development of disease or the maintenance of health. To manage the complexity inherent in this approach, functional medicine has adopted practical models for obtaining and evaluating clinical information that leads to individualized patient-centered therapies. Historically, the word functional was used somewhat pejoratively in medicine. It implied a disability associated with either a geriatric or psychiatric problem. The authors suggest, however, that this is a very limited definition of an extremely useful word. The medical profession

*Previous edition contributor

2

PRINCIPLES Seven basic principles characterize the functional medicine paradigm: • Acknowledging the biochemical individuality of each human being, based on the concepts of genetic and environmental uniqueness • Incorporating a patient-centered rather than a disease-centered approach to treatment

CHAPTER 1 

Functional Medicine: A 21st-Century Model of Patient Care and Medical Education

The Functional Medicine Tree

Cardiology

Pulmonary

Endocrinology

Urology

Organ System Diagnosis

Gastroenterology

Hepatology Neurology

Immunology

Signs and Symptoms

The Fundamental Organizing Systems and Core Clinical Imbalances Assimilation

Energy

Digestion, Absorption, Microbiota/Gl, Respiration

Energy regulation, Mitochondrial function

Cardiovascular, Lymphatic systems

Biotransformation and Elimination

Structural Integrity

Defence and Repair

Toxicity, Detoxification

From the subcellular membranes to the musculoskeletal system

Immune system, Inflammatory processes, Infection and microbiota

Transport

Communication

Endocrine, Neurotransmitters, Immune messengers, Cognition

Antecedents, Triggers, and Mediators Mental, Emotional, Spiritual Influences

Genetic Predisposition

Experiences, Attitudes, Beliefs

Relationships

Sleep & Relaxation Exercise & Movement

Stress Nutrition

Personalizing Lifestyle and Environmental Factors Version 2

© 2015 The Institute for Functional Medicine

Fig. 1.1  The continuum of health and health care: the functional medicine tree. (Courtesy the Institute for Functional Medicine.)

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• Seeking a dynamic balance among the internal and external factors in a patient’s body, mind, and spirit • Addressing the web-like interconnections of internal physiological factors • Identifying health as a positive vitality—not merely the absence of disease—and emphasizing those factors that encourage a vigorous physiology • Promoting organ, cellular, and subcellular function as the means of enhancing the health span, not just the life span, of each patient • Staying abreast of emerging research—a science- and evidence-based approach 

LIFESTYLE AND ENVIRONMENTAL FACTORS The building blocks of life, and the primary influences on them, are found at the base of the functional medicine tree graphic (see Fig. 1.1). When we talk about influencing gene expression, we are interested in the interaction between lifestyle and environment in the broadest sense and any genetic predispositions with which a person may have been born— in a word, the epigenome. (Epigenetics is the study of how environmental factors can affect gene expression without altering the actual DNA sequence and how these changes can be inherited through generations.) Many environmental factors that affect gene expression are (or appear to be) a matter of choice (such as diet and exercise), others are very difficult for the individual patient to alter or escape (air and water quality, toxic exposures), and still others may be the result of unavoidable accidents (trauma, exposure to harmful microorganisms). Some factors that may appear modifiable are heavily influenced by the patient’s economic status—if you are poor, for example, it may be impossible to choose more nutritious food, decrease stress in the workplace and at home, or take the time to exercise and rest properly. Existing health status is also a powerful influence on the patient’s ability to alter environmental input. If you have chronic pain, exercise may be extremely difficult; if you are depressed, self-activation is a major challenge. The influence of these lifestyle and environment factors on the human organism is indisputable,1,2 and they are often powerful agents in the attempt to restore health. Neglecting to address them in favor of merely writing a prescription—whether for pharmaceutical agents, nutraceuticals, or botanicals—means the cause of the underlying dysfunction may itself remain unaddressed and further able to contribute to the genesis of other disease conditions. In general terms, the following factors should be considered when working to reverse dysfunction or disease and restore health: • Diet (type, quality, and quantity of food; food preparation; calories, fats, proteins, carbohydrates) • Nutrients (both dietary and supplemental) • Air and water • Microorganisms (and the general condition of the soil in which food is grown) • Physical exercise • Trauma • Psychosocial and spiritual factors, such as meaning and purpose, relationships, work, community, economic status, stress, and belief systems • Xenobiotics • Radiation 

FUNDAMENTAL PHYSIOLOGICAL PROCESSES There are certain physiological processes that are necessary to life. These are the “upstream” processes that can go awry and create “downstream” dysfunctions that eventually become expressed as

disease entities. Functional medicine requires that clinicians consider these in evaluating patients so that interventions can target the most fundamental level possible. These processes are as follows: 1. Communication • Intracellular • Intercellular • Extracellular 2. Bioenergetics/energy transformation 3. Assimilation 4. Structural integrity 5. Biotransformation/elimination 6. Defense and repair 7. Transport/circulation These fundamental physiological processes are usually taught early in health professions curricula, where they are appropriately presented as the foundation of modern, scientific patient care. Unfortunately, subsequent training in the clinical sciences often fails to fully integrate knowledge of the functional mechanisms of disease with therapeutics and prevention, emphasizing organ system diagnosis instead.3 Focusing predominantly on organ-system diagnosis without examining the underlying physiology that produced the patient’s signs, symptoms, and disease often leads to managing patient care by matching diagnosis to pharmacology. The job of the health care provider then becomes a technical exercise in finding the drug or procedure that best fits the diagnosis (not necessarily the patient or the underlying physiological dysfunction), leading to a significant curtailment of critical thinking pathways: “Medicine, it seems, has little regard for a complete description of how myriad pathways result in any clinical state.”4 Even more important, pharmacological treatments (and even natural remedies) are often prescribed without careful consideration of their physiological effects across all organ systems, physiological processes, and genetic variations.5 This was notably exemplified by the cyclooxygenase-2 inhibitor drugs that were so wildly successful on their introduction, only to be subsequently withdrawn or substantially narrowed in use because of collateral damage.6,7 

CORE CLINICAL IMBALANCES The functional medicine approach to assessment, both before and after diagnosis, charts a course using different navigational assumptions. Every health condition instigates a quest for information centered on understanding when and how the specific biological system(s) under examination became dysregulated and began manifesting dysfunction and/or disease. Analyzing all the elements of the patient’s story, the signs and symptoms, and the laboratory assessment through a matrix focused on functionality requires analytical thinking and a willingness on the part of the clinician to reflect deeply on the underlying biochemistry and physiology. The foundational principles of how the human organism functions—and how its systems communicate and interact—are essential to the process of linking ideas about multifactorial causation with the perceptible effects called disease or dysfunction. To assist clinicians in this process, functional medicine identified and organized a set of core clinical imbalances that are linked to the fundamental physiological processes (organizing systems). These serve to marry the mechanisms of disease with the manifestations and diagnoses of disease. Many common underlying pathways of disease are reflected in these clinical imbalances. The following list of imbalanced systems and processes is not definitive, but some of the most common examples are provided. We recommend that the organizing systems be considered in the order as shown in the following list: • Digestion • Absorption

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5

One Condition – Many Imbalances Inflammation

Endocrine

Genetics and epigenetics

Diet and exercise

Mood disorders

OBESITY One Imbalance – Many Conditions INFLAMMATION

Heart disease Depression Arthritis Cancer Diabetes Fig. 1.2  Core clinical imbalances—multiple influences. (Courtesy the Institute for Functional Medicine.)

• Microbiome/gastrointestinal • Respiration • Immune system • Inflammatory processes • Infection and microbiome • Energy regulation • Mitochondrial function • Toxicity • Detoxification • Endocrine • Neurotransmitter • Immune messengers • Cognition • From the subcellular membranes • To the musculoskeletal system Using this construct, it becomes much clearer that one disease and/ or condition may have multiple causes (i.e., multiple clinical imbalances), just as one fundamental imbalance may be at the root of many seemingly disparate conditions (Fig. 1.2). The most important precept to remember about functional medicine is that restoring balance—in the patient’s lifestyle and/or environment and in the body’s fundamental physiological processes—is the key to restoring health. 

to acute or chronic illness. For a person who is ill, antecedents form the illness diathesis. From the perspective of prevention, they are risk factors. Knowledge of antecedents provides a rational structure for the organization of preventive medicine and public health. Medical genomics seeks to better understand disease by identifying the phenotypic expression of disease-related genes and their products. The application of genomic science to clinical medicine requires the integration of antecedents (genes and the factors controlling their expression) with mediators (the downstream products of gene activation). Mediators, triggers, and antecedents are not only key biomedical concepts; they are also important psychosocial concepts. In person-centered diagnosis, the mediators, triggers, and antecedents for each person’s illness form the focus of the clinical investigation.

Antecedents and the Origins of Illness Understanding the antecedents of illness helps the physician understand the unique characteristics of each patient as they relate to his or her current health status. Antecedents may be thought of as congenital or developmental. The most important congenital factor is gender: women and men differ sharply in susceptibility to many disorders. The most important developmental factor is age; what ails children is rarely the same as what ails the elderly. Beyond these obvious factors lies a diversity as complex as the genetic differences and separate life experiences that distinguish one person from another. 

ANTECEDENTS, TRIGGERS, AND MEDIATORS8

Triggers and the Provocation of Illness

What modern science has taught us about the genesis of disease can be represented by three words: triggers, mediators, and antecedents. Triggers are discrete entities or events that provoke disease or its symptoms. Microbes are an example. The greatest scientific discovery of the 19th century was the microbial etiology of the major epidemic diseases. Triggers are usually insufficient in and of themselves for disease formation; however, host response is an essential component. It is, therefore, the functional medicine practitioner’s job to know not just the patient’s ailments or diagnoses but also the physical and social environment in which illness occurs, the dietary habits of the person (present diet and preillness diet), his or her beliefs about the illness, the effect of illness on social and psychological function, factors that aggravate or ameliorate symptoms, and factors that predispose to illness or facilitate recovery. This information is necessary for establishing a functional medicine treatment plan. Identifying the biochemical mediators that underlie host responses was the most productive field of biomedical research during the second half of the 20th century. Mediators, as the word implies, do not cause disease. They are intermediaries that contribute to the manifestation and/or continuation of disease. Antecedents are factors that predispose

A trigger is anything that initiates an acute illness or the emergence of symptoms. The distinction between a trigger and a precipitating event is relative, not absolute; the distinction helps organize the patient’s story. As a general rule, triggers only provoke illness as long as the person is exposed to them (or for a short while afterward), whereas a precipitating event initiates a change in health status that persists long after the exposure ends. Common triggers include physical or psychic trauma, microbes, drugs, allergens, foods (or even the act of eating or drinking), environmental toxins, temperature change, stressful life events, adverse social interactions, and powerful memories. For some conditions, the trigger is such an essential part of our concept of the disease that the two cannot be separated; the disease is either named after the trigger (e.g., strep throat) or the absence of the trigger negates the diagnosis (e.g., concussion cannot occur without head trauma). For chronic ailments like asthma, arthritis, or migraine headaches, multiple interacting triggers may be present. All triggers, however, exert their effects through the activation of host-derived mediators. In closed-head trauma, for example, activation of N-methyl-d-aspartic acid receptors, induction of nitric oxide synthase, and liberation of free intraneuronal calcium

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BOX 1.1  Common Illness Mediators Biochemical Hormones Neurotransmitters Neuropeptides Cytokines Free radicals Transcription factors  Subatomic Ions Electrons Electrical and magnetic fields  Cognitive/Emotional Fear of pain or loss Feelings or personal beliefs about illness Poor self-esteem, low perceived self-efficacy Learned helplessness Lack of relevant health information  Social/Cultural Reinforcement for staying sick Behavioral conditioning Lack of resources because of social isolation or poverty The nature of the sick role and the doctor–patient relationship

determine the late effects. Intravenous magnesium at the time of trauma attenuates the severity by altering the mediator response.9,10 Sensitivity to different triggers often varies among persons with similar ailments. A prime task of the functional practitioner is to help patients identify important triggers for their ailments and develop strategies for eliminating them or diminishing their virulence. 

Mediators and the Formation of Illness A mediator is anything that produces or perpetuates symptoms or damages tissues of the body, including certain behaviors. Mediators vary in form and substance. They may be biochemical (e.g., prostanoids and cytokines), ionic (e.g., hydrogen ions), social (e.g., reinforcement for staying ill), psychological (e.g., fear), or cultural (e.g., beliefs about the nature of illness). A list of common mediators is presented in Box 1.1. Illness in any single person usually involves multiple interacting mediators. Biochemical, psychosocial, and cultural mediators interact continuously in the formation of illness. 

CONSTRUCTING THE MODEL Assessment Combining the principles, lifestyle and environment factors, fundamental physiological processes, antecedents, triggers, mediators, and core clinical imbalances demands a new architecture for gathering and sorting information for clinical practice—in effect, a new heuristic to serve the practice of functional medicine. (Heuristics are rules of thumb—ways of thinking or acting—that develop through experimentation and enable more efficient and effective processing of data.) This new model includes an explicit emphasis on principles and mechanisms that infuse meaning into the diagnosis and deepen the clinician’s understanding of the multivalent contributors to physiological dysfunction. Any methodology for constructing a coherent story and an effective therapeutic plan in the context of complex chronic illness must be flexible and adaptive. Like an accordion file that compresses

and expands upon demand, the amount and kind of data collected will necessarily change in accordance with the patient’s situation and the clinician’s time and ability to piece together the underlying threads of dysfunction. The conventional assessment process involving the chief complaint, history of present illness, and past medical history sections must be expanded (Fig. 1.3) to include a thorough investigation of antecedents, triggers, and mediators and a systematic evaluation of any imbalances within the fundamental organizing systems. Personalized medical care without this expanded investigation falls short. 

The Functional Medicine Matrix Model Distilling the data from the expanded history, physical examination, and laboratory findings into a narrative storyline that includes antecedents, triggers, and mediators can be challenging. Key to developing a thorough narrative is organizing the story using the Functional Medicine Matrix Model form (Fig. 1.4). The matrix form helps organize and prioritize information and also clarifies the level of present understanding, thus illuminating where further investigation is needed. For example: • Indicators of inflammation on the matrix might lead the clinician to request tests for specific inflammatory markers (such as highly sensitive C-reactive protein, interleukin levels, and/or homocysteine). • Essential fatty acid levels, methylation pathway abnormalities, and organic acid metabolites help determine the adequacy of dietary and nutrient intakes. • Markers of detoxification (glucuronidation and sulfation, cytochrome P450 enzyme heterogeneity) can determine the functional capacity for molecular biotransformation. • Neurotransmitters and their metabolites (vanilmandelate, homovanillate, 5-hydroxyindoleacetate, quinolinate) and hormone cascades (gonadal and adrenal) have obvious utility in exploring messenger molecule balance. • Computed tomographic scans, magnetic resonance imaging (MRI), or plain radiographs extend the view of the patient’s structural dysfunctions. The use of bone scans, dual-energy x-ray absorptiometry scans, or bone resorption markers11,12 can be useful in further exploring the web-like interactions of the matrix. • Newer, useful technologies such as functional MRIs, single-photon emission computed tomography, and positron emission tomographic scans offer a more comprehensive assessment of metabolic function within organ systems. It is the process of completing a comprehensive history and physical using the expanded functional medicine heuristic and then charting these findings on the matrix that best directs the choice of diagnostic evaluations and successful treatment. Therapies should be chosen for their potential effect on the most significant imbalances of the particular patient. A completed matrix form facilitates review of common pathways, mechanisms, and mediators of disease and helps clinicians select points of leverage for treatment strategies. However, even with the matrix as an aid to synthesizing and prioritizing information, it can be very useful to consider the effect of each variable at five different levels: 1. Whole-body interventions: Because the human organism is a complex adaptive system, with countless points of access, interventions at one level will affect points of activity in other areas as well. For example, improving the patient’s sleep beneficially influences the immune response, melatonin levels, and T-cell lymphocyte levels and helps decrease oxidative stress. Exercise reduces stress, improves insulin sensitivity, and improves detoxification. Reducing stress (and/or improving stress management) reduces cortisol

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7

Chief Complaint (CC) History of Present Illness (HPI) Past Medical History (PMH) – Explore antecedents, triggers, and mediators of CC, HPI, and PMH Family Medical History – Genetic predispositions? Review of Organ Systems (ROS) Medication and Supplement History Dietary History Social, Lifestyle, Exercise History Physical Examination (PE) Laboratory and Imaging Evaluations Explore Core Clinical Imbalances: Assimilation Imbalances Digestion Absorption Microbiota/GI Respiration Defense and Repair Imbalances Immune system Inflammatory processes Infection and microbiota Energy Imbalances Energy regulation Mitochondrial function Biotransformation and Elimination Imbalances Toxicity Detoxification Communication Imbalances Endocrine Neurotransmitter Immune messengers Cognition Structural Integrity Imbalances From the subcellular membranes to the musculoskeletal system Initial Assessment: – Enter data on Matrix form; look for common themes – Review underlying mechanisms of disease – Recapitulate patient’s story – Organ system-based diagnosis – Functional medicine assessment: underlying mechanisms of disease; genetic and environmental influences Treatment Plan: – Individualized – Dietary, lifestyle, environmental – Nutritional, botanical, psychosocial, energetic, spiritual – May include pharmaceuticals and/or procedures Fig. 1.3  Expanding the accordion file: the functional medicine assessment heuristic. (Courtesy the Institute for Functional Medicine.)

levels, improves sleep, improves emotional well-being, and reduces the risk of heart disease. Changing the diet has myriad effects on health, from reducing inflammation to reversing coronary artery disease. 2. Organ-system interventions: These interventions are used more frequently in the acute presentation of illness. Examples include splinting; draining lesions; repairing lacerations; reducing fractures, pneumothoraxes, hernias, or obstructions; or removing a stone to reestablish whole-organ function. There are many interventions that improve organ function. For example, bronchodilators improve air exchange, thereby decreasing hypoxia, reducing oxidative stress, and improving metabolic function and oxygenation in a patient with reactive airway disease. 3. Metabolic or cellular interventions: Cellular health can be addressed by ensuring the adequacy of macronutrients, essential amino acids,

vitamins, and cofactor minerals in the diet (or, if necessary, from supplementation). An individual’s metabolic enzyme polymorphisms can profoundly affect his or her nutrient requirements. For example, adding conjugated linoleic acid to the diet can alter the peroxisome proliferator–activated receptor system, affect body weight, and modulate the inflammatory response.13–15 However, in a person who is diabetic or insulin resistant, adding conjugated linoleic acid may induce hyperproinsulinemia, which is detrimental.16,17 Altering the types and proportions of carbohydrates in the diet may increase insulin sensitivity, reduce insulin secretion, and fundamentally alter metabolism in the insulin-resistant patient. Supporting liver detoxification pathways with supplemental glycine and N-acetylcysteine improves the endogenous production of adequate glutathione, an essential antioxidant in the central nervous system and gastrointestinal tract.

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FUNCTIONAL MEDICINE MATRIX Retelling the Patient’s Story Antecedents (Predisposing Factors— Genetic/Environmental)

Triggering Events (Activators)

Physiology and Function: Organizing the Patient’s Clinical Imbalances Assimilation

Defense & Repair (e.g., Immune, Inflammation, Infection/Microbiota)

(e.g., Digestion, Absorption, Microbiota/GI, Respiration)

Structural Integrity (e.g., from Subcellular Membranes to Musculoskeletal Structure)

Mental

Emotional

e.g., cognitive function, perceptual patterns

e.g., emotional regulation, grief, sadness, anger, etc.

Energy (e.g., Energy Regulation, Mitochondrial Function)

Spiritual Mediators/Perpetuators (Contributors)

e.g., meaning & purpose, relationship with something greater

Communication (e.g., Endocrine, Neurotransmitters, Immune messengers)

Biotransformation & Elimination (e.g., Toxicity, Detoxification)

Transport (e.g., Cardiovascular, Lymphatic System)

Modifiable Personal Lifestyle Factors Sleep & Relaxation

Name:

Exercise & Movement

Nutrition

Date:

Stress

CC:

Relationships

© 2015 Institute for Functional Medicine Version3

Fig. 1.4  The Functional Medicine Matrix Model. (Courtesy the Institute for Functional Medicine.)

4. Subcellular/mitochondrial interventions: There are many examples of nutrients that support mitochondrial function.18,19 Inadequate iron intake causes oxidants to leak from mitochondria, damaging mitochondrial function and mitochondrial DNA. Making sure there is sufficient iron helps alleviate this problem. Inadequate zinc intake (found in more than 10% of the U.S. population) causes oxidation and DNA damage in human cells.19 Ensuring the adequacy of antioxidants and cofactors for the at-risk individual must be considered in each part of the matrix. Carnitine, for example, is required as a carrier for the transport of fatty acids from the cytosol into the mitochondria, improving the efficiency of β-oxidation of fatty acids and resultant adenosine triphosphate production. In patients who have lost significant weight, carnitine undernutrition can result in fatty acids undergoing ωoxidation, a far less efficient form of metabolism.20 Patients with low carnitine may also respond to riboflavin supplementation.20 5.  Subcellular/gene-expression interventions: Many compounds interact at the gene level to alter cellular response, thereby affecting health and healing. Any intervention that alters nuclear factor-κB entering the nucleus, binding to DNA, and activating genes that encode inflammatory modulators, such as interleukin-6 (and thus C-reactive protein), cyclooxygenase-2, interleukin-1, lipoxygenase, inducible nitric oxide synthase, tumor necrosis factor-α, or a number of adhesion molecules, will affect many disease conditions.21,22 There are many ways to alter the environmental triggers for nuclear factor-κB, including lowering oxidative stress; altering emotional stress; and consuming adequate phytonutrients, antioxidants, alpha-lipoic acid, eicosapentaenoic acid, docosahexaenoic acid,

and γ-linoleic acid.21 Adequate vitamin A allows the appropriate interaction of vitamin A–retinoic acid with more than 370 genes.23 Vitamin D in its most active form intercalates with a retinol protein and the DNA exon and modulates many aspects of metabolism, including cell division in both healthy and cancerous breast, colon, prostate, and skin tissue.24 Vitamin D has key roles in controlling inflammation, calcium homeostasis, bone metabolism, cardiovascular and endocrine physiology, and healing.24 Experience using this model, along with improved pattern-recognition skills, will often lessen the need for extensive laboratory assessments. However, there will always be certain clinical conundrums that simply cannot be assessed without objective data, and for most patients, there may be an irreducible minimum of laboratory assessments required to accumulate information. For example, in the clinical workup of autism spectrum disorders in children, heavy-metal exposure and toxicity may play an important role. The heavy-metal body burden cannot be sensibly assessed without laboratory studies. In most initial workups, laboratory and imaging technologies can be reserved for those complex cases in which the initial interventions prove insufficient to the task of functional explication. When clinical acumen and educated steps in both assessments and therapeutic trials do not yield expected improvement, laboratory testing often provides rewarding information. This is frequently the context for focused genomic testing. 

The Healing Partnership No discussion of the functional medicine model would be complete without mention of the therapeutic relationship. Partnerships are

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Functional Medicine: A 21st-Century Model of Patient Care and Medical Education

formed to achieve an objective. For example, a business partnership forms to engage in commercial transactions for financial gain; a marriage partnership forms to build a caring, supportive, home-centered environment. A healing partnership forms to heal the patient through the integrated application of both the art of medicine (insight driven) and the science of medicine (evidence driven). An effective partnership requires that trust and rapport be established. Patients must feel comfortable telling their stories and revealing intimate information and significant events. In the 20th century, contemporary medicine, traditionally considered a healing profession, evolved away from the role of healing the sick to that of curing disease through modern science. Research into this transition revealed that healing was traditionally associated with themes of wholeness, narrative, and spirituality. Professionals and patients alike report healing as an intensely personal, subjective experience involving a reconciliation of meaning for an individual and a perception of wholeness. The biomedical model as currently configured no longer encompasses these characteristics. Contemporary medicine considers the wholeness of healing to be beyond its orthodoxy—the domain of the nonscientific and nonmedical.25 We disagree. To grasp the profound importance of the healing partnership to the creation of a system of medicine adequate to the demands of the 21st century, an emerging body of relevant research was reviewed.26–28 As Louise Acheson, MD, MS, associate editor of the Annals of Family Practice, articulated insightfully in that journal29: “It is challenging to research this ineffable process called healing.” Hsu and colleagues asked focus groups of nurses, physicians, medical assistants, and randomly selected patients to define healing and describe what facilitates or impedes it.30 The groups arrived at surprisingly convergent definitions: “Healing is a dynamic process of recovering from a trauma or illness by working toward realistic goals, restoring function, and regaining a personal sense of balance and peace.” They heard from diverse participants that “healing is a journey” and “relationships are essential to healing.” Research into the role of healing in the medical environment has generated some thoughtful and robust investigations. Scott et  al.’s26 research into the healing relationship found very similar descriptions to those of Hsu et  al.30 The participants in the study27 articulated aspects of the healing partnership as follows: 1. Valuing and creating a nonjudgmental emotional bond 2. Appreciating power and consciously managing clinician power in ways that would most benefit the patient 3. Abiding and displaying a commitment to caring for patients over time Three relational outcomes result from these processes: trust, hope, and a sense of being known. Clinician competencies that facilitate these processes are self-confidence, emotional self-management, mindfulness, and knowledge.27 In this rich soil, the healing partnership flourishes. The characteristics of a conventional therapeutic encounter are fundamentally different from a healing partnership, and each emerges from specific emphases in training. In the therapeutic encounter, the relationship forms to assess and treat a medical problem using (usually) an organ-system structure, a differential diagnosis process, and a treatment toolbox focused on pharmacology and medical procedures. The therapeutic encounter pares down the information flow between physician and patient to the minimum needed to identify the organ-system domain of most probable dysfunction, followed by a sorting system search (the differential diagnosis heuristic). The purpose of this relationship is to arrive at the most probable diagnosis as quickly as possible and select an intervention based on probable efficacy. The relationship is a left-brain–guided conversation controlled

9

by the clinician and characterized by algorithmic processing and statistical thinking.31,32 The functional medicine healing partnership forms with a related but broader purpose: to help the patient heal by identifying the underlying mechanisms and influences that initiated and continue to mediate the patient’s illness(es). This type of relationship emphasizes shared responsibility for identifying the causes of the patient’s condition and achieving insight about enduring solutions. The healing partnership is critical to the delivery of personalized systems of medicine and to managing the uncertainty (choices under risk) inherent in clinical practice. In the healing partnership, the appropriate utilization and integration of left-brain and right-brain functions are found. In language, we have the fullest expression of the integration of leftand right-brain function. Language is so complex that the brain has to process it in different ways simultaneously—both denotatively and connotatively. For complexity and nuance to emerge in language, the left brain needs to see the trees, and the right brain helps us see and understand the forest.33,34 The starting point for creating a healing partnership is the patient’s experience. People, not diseases, can heal. Mindful integration of brain function is at the heart of a healing partnership. Some of the basic steps for establishing a healing partnership include the following: 1. Allowing patients to express, without interruption, their story about why they have come to see you. (Research focused on the therapeutic encounter has repeatedly found that clinicians interrupt the patient’s flow of conversation within the first 18 seconds or less, often denying the patient an opportunity to finish.35) The manner in which the patient frames the initial concerns often presages later insight into the root causes. Any interruption in this early stage of narrative moves the patient back into left-brain processing and away from insight.36 2. After focusing on the chief concerns, encouraging the patient’s narrative regarding the present illness(es). Clarifications can be elicited by further open-ended questioning (e.g., “Tell me more about that”; “What else do you think might be going on?”). During this portion of the interview, there is a switching back and forth between right- and left-brain functions. • During this conversation, signs and symptoms of the present illness are distributed by the practitioner into the Functional Medicine Matrix Model form as previously described. • Analysis of the data thus collected proceeds by assessing probable underlying causes—based on evidence about common underlying mechanisms of disease—and ongoing mediators of the disease. 3.  Next, conveying to the patient in the simplest terms possible that to achieve lasting solutions to the problem(s) for which the patient has come seeking help, a few fundamental questions must be asked and answered to understand the problem in the context of the patient’s personal life. This framing of the interview process moves the endeavor from a left-brain compilation to a narrative that encourages insight—based on complex pattern recognition— about the root causes of the problem. 4. At this stage, control is shared with the patient: “Without your help, we cannot understand your medical problem in the depth and breadth you deserve.” Implementing this shared investigation can be facilitated by certain approaches:

a.  For determining antecedent conditions, the following questions are useful: • When was the last time you felt well? When were you free of this problem? • What were the circumstances surrounding the appearance of the problem? • Have similar problems appeared in family members?

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Philosophy of Natural Medicine

One Condition, Many Causes

One Cause, Many Conditions

Omega-3 Deficiency

Depression

Antibiotic Use

Low Thyroid

Heart Disease

Arthritis

DEPRESSION

Pre-Diabetes

INFLAMMATION

Vitamin D Deficiency

Diabetes

Cancer

Cause

Condition

Fig. 1.5  Overview of the functional medicine (FM) model. (Courtesy the Institute for Functional Medicine.)

b. For triggers, the following question is critical: • What conditions, activities, or events seemed to initiate the problem? (Microbes and stressful personal events are examples but illustrate quite different categories of triggers. Triggers by themselves are usually insufficient for disease formation, so triggers must be viewed within the context of the antecedent conditions.) c. Mediators of the problem are influences that help perpetuate it. • There can be specific mediators of diseases in the patient’s activities, lifestyle, and environment. Many diverse factors can affect the host’s response to stressors. • Any of the core clinical imbalances, discussed previously and shown on the Functional Medicine Matrix Model, can transform what might have been a temporary change in homeostasis into a chronic allostatic condition. It helps at this juncture to emphasize again that the following issues are elemental in forming a healing partnership: • Only the patient can inform the partnership about the conditions that provided the soil from which the problem(s) under examination emerged. The patient literally owns the keys to the joint deliberation that can provide insight into the process of achieving a healing outcome. • The professional brings experience, wisdom, tools, and techniques and works to create the context for a healing insight to emerge. • The patient’s information, input, mindful pursuit of insight, and engagement become “the horse before the cart.” The cart carries the clinician—the person who guides the journey using evidence, experience, and judgment and who contributes the potential for expert insight.

The crux of the healing partnership is an equal investment of focus by both clinician and patient. They work together to identify the right places to apply leverage for change. Patients must commit to engage both their left-brain skills and their right-brain function to inform and guide the exploration to the next steps in assessment, therapy, understanding, and insight. Clinicians must also engage both the left-brain computational skills and the right-brain pattern-recognition functions that, when used together, can generate insight about the patient’s story. An overview of the functional medicine model is given in Fig. 1.5. 

INTEGRATION OF CARE Functional medicine explicitly recognizes that no single profession can cover all the viable therapeutic options. Interventions and practitioners will differ by training, licensure, specialty focus, and even by beliefs and ethnic heritage. However, all health care disciplines (and all medical specialties) can—to the degree allowed by their training and licensure and assuming a good background in Western medical science—use a functional medicine approach, including integrating the matrix as a basic template for organizing and coupling knowledge and data. Consequently, functional medicine can provide a common language, a flexible architecture, and a unified model to facilitate integrated and integrative care. Regardless of the discipline in which the clinician has been trained, developing a network of capable, collaborative practitioners with whom to comanage challenging patients and to whom referrals can be made for therapies outside the primary clinician’s own expertise will enrich patient care and strengthen the clinician–patient relationship.

REFERENCES See www.expertconsult.com for a complete list of references.

REFERENCES 1. Goetzel RZ. Do prevention or treatment services save money? The wrong debate. Health Aff. 2009;28(1):37–41. 2. Probst-Hensch NM. Chronic age-related diseases share risk factors: do they share pathophysiological mechanisms and why does that matter? Swiss Med Wkly. 2010;140:w13072. Available at http://www.smw.ch/ index.php?id=smw-2010-13072. Accessed October 11, 2010. 3. Magid CS. Developing tolerance for ambiguity. JAMA. 2001;285(1):88. 4. Rees J. Complex disease and the new clinical sciences. Science. 2002;296: 698–701. 5. Radford T. Top scientist warns of “sickness” in US health system. BMJ. 2003;326:416. https://doi.org/10.1136/bmj.326.7386.416/b. 6. Vioxx. Lessons for Health Canada and the FDA. CMAJ. 2005;172(11):5. 7. Juni P, Nartey L, Reichenbach S, et al. Risk of cardiovascular events and rofecoxib: cumulative meta-analysis. Lancet. 2004;364:2021–2029. 8. This section was excerpted and adapted from Galland L. Patient-centered care: antecedents triggers, and mediators. In: Textbook of Functional Medicine, Ch. 8. 9. Cernak I, Savic VJ, Kotur J, et al. Characterization of plasma magnesium concentration and oxidative stress following graded traumatic brain injury in humans. J Neurotrauma. 2000;17(1):53–68. 10. Vink R, Nimmo AJ, Cernak I. An overview of new and novel pharmacotherapies for use in traumatic brain injury. Clin Exp Pharmacol Physiol. 2001;28(11):919–921. 11. Yu SL, Ho LM, Lim BC, Sim ML. Urinary deoxypyridinoline is a useful biochemical bone marker for the management of postmenopausal osteoporosis. Ann Acad Med Singapore. 1998;27(4):527–529. 12. Palomba S, Orio F, Colao A, et al. Effect of estrogen replacement plus low-dose alendronate treatment on bone density in surgically postmenopausal women with osteoporosis. J Clin Endocrinol Metab. 1002;87(4): 1502–1508. 13. Moya-Camarena SY, Vanden Heuvel JP, Blanchard SG, et al. Conjugated linoleic acid is a potent naturally occurring ligand and activator of PPARa. J Lipid Res. 1999;40:1426–1433. 14. Gaullier JM, Halse J, Hoye K, et al. Conjugated linoleic acid supplementation for 1 y reduces body fat mass in healthy overweight humans. Am J Clin Nutr. 2004;79:1118–1125. 15. O’Shea M, Bassaganya-Riera J, Mohede IC. Immunomodulatory ­properties of conjugated linoleic acid. Am J Clin Nutr. 2004;79(S): 1199S–1206S. 16. Malloney F, Yeow TP, Mullen A, et al. Conjugated linoleic acid supplementation, insulin sensitivity, and lipoprotein metabolism in patients with type 2 DM. Am J Clin Nutr. 2004;80(4):887–895. 17. Riserus U, Vessby B, Arner P, Zethelius B. Supplementation with CLA induces hyperproinsulinaemia in obese men: close association with impaired insulin sensitivity. Diabetalogia. 2004;47(6):1016–1019. 18. Ames BN. The metabolic tune-up: metabolic harmony and disease prevention. J Nutr. 2003;133:1544S–1548S. 19. Ames BN, Elson-Schwab I, Silver EA. High-dose vitamin therapy stimulates variant enzymes with decreased coenzyme binding affinity (increased Km): relevance to genetic disease and polymorphisms. Am J Clin Nutr. 2002;75(4):616–658. 20. Bralley JA, Lord RS. Laboratory Evaluations in Molecular Medicine: Nutrients, Toxicants and Metabolic Controls. Atlanta: Institute for Advances in Molecular Medicine; 2001. 21. Yamamoto Y, Gaynor RB. Therapeutic potential of inhibition of the NFkB pathway in the treatment of inflammation and cancer. J Clin Invest. 2001;107(2):135–142.

22. Tak PP, Firestein GS. NF-kB: a key role in inflammatory disease. J Clin Invest. 2001;107(1):7–11. 23. Balmer JE, Blomhoff R. Gene expression regulation by retinoic acid. J Lipid Res. 2002;43:1773–1808. 24. Holick MF. Sunlight and vitamin D for bone health and prevention of autoimmune diseases, cancers, and cardiovascular diseases. Am J Clin Nutr. 2004;80(suppl 6). 1678S–1688S. 25. Egnew TR. The meaning of healing: transcending suffering. Ann Fam Med. 2005;3(3):255–262. 26. Scott JG, Cohen D, DiCicco-Bloom B, et al. Understanding healing relationships in primary care. Ann Fam Med. 2008;6(4):315–322. 27. Miller WL, Crabtree BF, Duffy MB, et al. Research guidelines for assessing the impact of healing relationships in clinical medicine. Altern Ther Health Med. 2003;9(suppl 3):A80–A95. 28. Jackson C. Healing ourselves, healing others? first in a series. Holist Nurs Pract. 2004;18(2):67–81. 29. Acheson L. Community care, healing, and excellence in research. Ann Fam Med. 2008;6:290–291. 30. Hsu C, Phillips WR, Sherman KJ, et al. Healing in primary care: a vision shared by patients, physicians, nurses, and clinical staff. Ann Fam Med. 2008;6(4):307–314. 31. Brown M, Brown G, Sharma S. Evidence-Based to Value-Based Medicine. Chicago, IL: AMA Press; 2005. 32. Sackett DL, Straus SE, Richardson WS, Rosenberg W, Haynes RB. Evidence-Based Medicine: How to Practice and Teach EBM (3rd ed.). New York: Churchill Livingstone. 33. Fiore S, Schooler J. Right hemisphere contributions to creative problem solving: converging evidence for divergent thinking. In: Beeman M, Chiarello C, eds. Right hemisphere language comprehension: perspectives from cognitive neuroscience. Philadelphia, PA: Erlbaum Publishing; 1998:255– 284. 34. Seger CA, Desmond JE, Glover GH, et al. fMRI evidence for right hemisphere involvement in processing unusual semantic relationships. Neuropsychology. 2000;14:361–369. 35. Beckman DB, et al. The effect of physician behavior on the collection of data. Ann Intern Med. 1984;101:692–696. 36. Lehrer J. The annals of science: the eureka hunt. The New Yorker. 2008:s40–s45.

BIBLIOGRAPHY Galland L, Lafferty H. Gastrointestinal Dysregulation: Connections to Chronic Disease. (Functional Medicine Monograph). Gig Harbor, WA: The Institute for Functional Medicine; 2008. Hedaya R, Quinn S. Depression: advancing the paradigm (Functional Medicine Monograph). Gig Harbor, WA: The Institute for Functional Medicine. In: Jones DS, ed. Textbook of functional medicine. Gig Harbor, WA: The Institute for Functional Medicine; 2008. Jones DS, Hofmann L, Quinn S. 21st Century Medicine: a New Model for Medical Education and Practice (White Paper). Gig Harbor, WA: The Institute for Functional Medicine; 2009. Lukaczer D, Jones DS, Lerman RH, et al. Clinical Nutrition: A Functional Approach. 2nd ed. Gig Harbor, WA: The Institute for Functional Medicine; 2004. Vasquez A. Musculoskeletal Pain: Expanded Clinical Strategies (Functional Medicine Monograph). Gig Harbor, WA: The Institute for Functional Medicine; 2008.

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2 A Hierarchy of Healing: The Therapeutic Order

A Unifying Theory of Naturopathic Medicine Stephen P. Myers, ND, BMed PhD, Pamela Snider, ND, Jared Zeff, ND, and Zora DeGrandpre*, MS, ND

OUTLINE A Brief History of Naturopathic Medicine, 11 Original Philosophy and Theory, 12 Modern Naturopathic Clinical Theory: the Process of Development, 13 A Theory of Naturopathic Medicine, 15 Illness and Healing as Process, 16 The Naturopathic Model in Acute Illness, 16 The Naturopathic Model in Chronic Illness, 17 The Determinants of Health, 18 Therapeutic Order and Naturopathic Assessment, 18 The Assessment Order: Components of a Vitalistic Assessment of Illness, Healing, and Health, 18

Therapeutic Order, 20 Acute and Chronic Concerns, 21 Establish the Conditions for Health, 21 Stimulate the Self-Healing Mechanisms, 22 Support Weakened or Damaged Systems or Organs, 23 Address Structural Integrity, 23 Address Pathology: Use Specific Natural Substances, Modalities, or Interventions, 23 Address Pathology: Use Specific Pharmacological or Synthetic Substances, 24 Suppress Pathology, 24 Theory in Naturopathic Medicine, 24

A BRIEF HISTORY OF NATUROPATHIC MEDICINE1

The profession went through a period of decline, marked with internal disunity and paralleled by the rise of biomedicine and the promise of wonder drugs. By 1957, there was only one naturopathic college left. By 1975, only eight states still licensed naturopathic physicians, and by 1979, there were only six. A survey conducted in 1980 revealed that there were only about 175 naturopathic practitioners still licensed and practicing in the United States and Canada.6 In contrast, in 1951, the number was approximately 3000.7 The decline of naturopathic medicine after a rapid rise was due to several factors. By the 1930s, a significant tension developed within the profession regarding clinical naturopathic practice based on traditional principles; the development of unified standards; and the role of experimental, reductionist science as an element of professional development.8,9 Many naturopathic doctors questioned the capacity for the reductionist scientific paradigm to research naturopathic medicine objectively in its full scope.8,10,11 This tension split the profession of naturopathic physicians from within after the death of Lust in the late 1940s, at a time when the profession was subject to both significant external forces and internal leadership challenges. This perception created a mistrust of science and research. Science was also frequently used as a bludgeon against naturopathic medicine, and the biases inherent in what became the dominant paradigm of scientific reductionism made a culture of scientific progress in the profession challenging. The discovery of effective antibiotics elevated the standard medical profession to dominant and unquestioned ­stature by

In 1900 Benedict Lust “invented” naturopathy, as an eclectic practice that combined many natural therapies and therapeutic systems under the umbrella of a comprehensive philosophy and system of practice based on the European nature cure movement that flourished in the 1800s. At the core of this philosophy was the vis medicatrix naturae (healing power of nature) and the naturalistic concept of vitalism. As such, naturopathic medicine has deep historical roots and represents a lineage of Western natural medicine that can be traced back to the Roman, Greek, Egyptian, and Mesopotamian cultures and, conceptually, to many traditional and indigenous world medicines. The modern naturopathic profession originated with Lust, and it grew under his tireless efforts. He crisscrossed the United States, lecturing and lobbying for legislation to license naturopathy, testifying for naturopaths indicted for practicing medicine without a license, and traveling to many events and conferences to help build the profession. He also wrote extensively, including two monthly newspapers (The Naturopath and Herald of Health) for nearly 40 years, to foster and popularize the profession, and through his efforts, the naturopathic profession grew rapidly.2–4 By the 1940s, naturopathic medicine had developed a number of 4-year medical schools and had achieved licensure in about one third of the United States, the District of Columbia, four Canadian provinces, and a number of other countries.3,5 *Previous edition contributor

11

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a culture that turned to mechanistic science as an unquestioned authority. The dawning of the atomic age reinforced a fundamental place for science in a society increasingly dominated by scientific discovery. In this culture, standard medicine, with its growing political and economic strength, was able to force the near elimination of naturopathic medicine through the repeal or “sunsetting” of licensure acts.2,3,12 In 1956, as the last early doctor of naturopathy (ND) educational program ended (at the Western States College of Chiropractic), several doctors, including Drs. Ralph Weiss, Charles Stone, W. Martin Bleything, and Frank Spaulding, created the National College of Naturopathic Medicine in Portland, Oregon, to keep the profession alive. However, that school was nearly invisible as the last vestige of a dying profession and rarely attracted as many as 10 new students a year. The profession was considered dead by its historical adversaries. The culture of America, dominated by standard medicine since the 1940s, however, began to change by the late 1960s. The promise of science and antibiotics was beginning to seem less than perfect. Chronic disease was increasing in prevalence as acute infection was becoming less predominant, and standard medicine had no “penicillin” for chronic diseases. In the late 1970s, scholars in family medicine proposed a biopsychosocial model of care in response to a prevailing perception of a growing crisis in standard medicine.13 The publication of Engel’s “The Need for a New Medical Model” in April 1977 signaled the founding of the field of family medicine based on a holistic philosophy. This shifting culture within standard medicine paralleled a broader social movement in support of alternative health practices and environmental awareness. Elements of the culture were rebelling against plastics and cheap synthetics, seeking more natural solutions. The publication of Rachael Carson’s Silent Spring in 1962, an indictment of chemical pesticides and environmental damage, marked a turning point in cultural thinking. In Silent Spring, Carson challenged the practices of agricultural scientists and the government and called for a change in the way humankind viewed the natural world.14 New evidence of the dangers of radiation, synthetic pesticides, and herbicides and environmental degradation from industrial pollution was creating a new ethic. Organic farming, natural fibers, and other similar possibilities were starting to capture attention. A few began seeking natural alternatives in medicine. By the late 1960s and early 1970s, enrollments at the National College of Naturopathic Medicine began to reach into the 20s. The 1974 class numbered 23 students. In 1975 the National College enrolled a class of 63 students.15 The profession was experiencing a resurgence. In 1978, with a desire to create a college based on science-based natural medicine, Joseph E. Pizzorno, ND, LM, and his colleagues—Les Griffith, ND, LM; Bill Mitchell, ND; and Sheila Quinn—created the John Bastyr College of Naturopathic Medicine in Seattle, Washington. With the creation of Bastyr, named after the eminent naturopathic physician Dr. John Bartholomew Bastyr (1912–1995), the profession entered a new phase. Not only did this new college double the profession’s capacity to produce new doctors, but it also firmly placed the profession on the ground of scientific research and validation. “Science-based natural medicine,” coined by Dr. Pizzorno, was a major driving force behind the creation and mission of Bastyr. Both Drs. Bastyr and Pizzorno had significant influence and leadership in achieving this focus. One of Dr. Bastyr’s important legacies was to establish a foundation and a model for reconciling the perceived conflict between science and the deeply established healing practices and principles of naturopathic medicine. Kirchfeld and Boyle4 described his landmark contribution as follows: Although naturopathic colleges in the early 1900s did include basic sciences training, it was not until Dr. John Bastyr (1912–1995) and his firm, efficient and professional leadership that science and

research-based training in natural medicine was inspired to reach its fullest potential. Dr. Bastyr, whose vision was one of “naturopathy’s empirical successes documented and proven by scientific methods,” was himself the prototype of the modern naturopathic doctor, who culls the latest findings from the scientific literature, applies them in ways consistent with naturopathic principles and verifies the results with appropriate studies. Bastyr also saw a tremendous expansion in both allopathic and naturopathic medical knowledge, and he played a major role in making sure the best of both were integrated into naturopathic medical education.4,16 Bastyr met Lust on two occasions and was closely tied to the nature cure tradition of Kneipp through two influential women: his mother, and his mentor, Dr. Elizabeth Peters, who studied with Father Kneipp. He effortlessly integrated the clinical theories and practices of naturopathy with the latest scientific studies and helped create a new and truly original form of modern primary clinical care within naturopathic medicine. He spent the 20th century preparing the nature cure of the 19th century for entry into the 21st century.2,16 Today’s philosophic debates within the profession are no longer about science. They now tend to center on both sides of the earlier debate and include challenges to the nature cure tradition. A current debate, for instance, is about the role of “green allopathy” within the profession: the tendency to use botanical medicine or nutritional supplements as a simple “green drug” or pharmaceutical replacement therapy. This is in contrast to implementing the full range of healing practices derived from the nature cure tradition and within the framework of the therapeutic order construct to stimulate health restoration as the foundation for reversing disease, alongside, or instead of, botanical medicine or nutritional supplements. Professional consensus appears strong that the full range of naturopathic healing practices must be retained, strengthened, and engaged in the process of education and scientific research and discovery in the 21st century.17–19 

ORIGINAL PHILOSOPHY AND THEORY Through the initial 50-year period of professional growth and development (1896–1945), naturopathic medicine had no clear and concise statement of identity. The profession was whatever Lust said it was. He defined “naturopathy” or “nature cure” as both a way of life and a concept of healing that used various natural means of treating human infirmities and disease states. The “natural means” were integrated into naturopathic medicine by Lust and others based on the emerging naturopathic theory of healing and disease etiology. The earliest therapies associated with the term involved a combination of American hygienics and Austro-Germanic nature cure and hydrotherapy. Leaders in this field included Kuhne, Lindlahr, Trall, Kellogg, Holbrook, Tilden, Graham, McFadden, Rikli, Thomson, and others who wrote foundational naturopathic medical treatises or developed naturopathic clinical theory, philosophy, and texts to enhance, agree with, and diverge from Lust’s original work.20–28 The bulk of professional theory was found in Lust’s magazines, Herald of Health and The Naturopath. These publications displayed the prodigious writings of Lust but did not contain a comprehensive and definitive statement of either philosophy or clinical theory. Lust often stated that all natural therapies fell under the purview of naturopathy. Several texts were considered as somewhat definitive by various aspects of the profession at different times. These texts included Adolph Just’s Return to Nature (1896), Louis Kuhne’s The New Science of Healing (1899), and the seven-volume Natural Therapeutics by Henry Lindlahr, MD, which was published in the early 1900s. Lindlahr’s Nature Cure (1913) was considered a seminal work in naturopathic theory, laying

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A Hierarchy of Healing: The Therapeutic Order

the groundwork for a systematic approach to naturopathic treatment and diagnosis. Lindlahr ultimately presented the most coherent naturopathic theory extant, summarized in his Catechism of Nature Cure, which presented a five-part therapeutic progression: 1. “Return to nature”—attending to the basics of diet, dress, exercise, rest, etc. 2. Elementary remedies—water, air, light, electricity 3. Chemical remedies—botanicals, homeopathy, etc. 4. Mechanical remedies—manipulations, massage, etc. 5. Mental/spiritual remedies—prayer, positive thinking, doing good works, etc.29 Lindlahr’s five-step therapeutic progression follows the Catechism’s disease causation model: “The primary cause of disease, barring accidental or surgical injury to the human organism and surroundings hostile to human life, is violation of Nature’s Laws.” The effects of violation of nature’s laws on the physical human organism are also the primary causes of disease because they inhibit normal function, lower vitality, and result in tissue destruction: Primary Lowered vitality Abnormal composition of blood and lymph Accumulation of waste, morbid matter, and poisons in the system Secondary Hereditary/constitutional Fevers, inflammation Mechanical luxations Weakening and loss of reason, will, etc.29 In 1948 Spitler wrote Basic Naturopathy, a Textbook,10 and in 1951 Wendel wrote Standardized Naturopathy.11 These texts presented somewhat different approaches; Spitler’s text emphasized theory and philosophy, whereas Wendel’s text was written, as evidenced by the title, to emphasize the standard naturopathic practices of the day, with an eye toward regulatory practice. In contrast, Kuts-Cheraux’s Naturopathic Materia Medica, written in 1953, was produced to satisfy a statutory demand by the Arizona legislature but persisted as one of the few extant guides of that era. Practitioners relied on a number of earlier texts, many of which arose from the German hydrotherapy practitioners30–35 or the eclectic school of medicine (a refinement and expansion of the earlier “Thomsonian” system of medicine)36–40 and predated the formal American naturopathic profession (1900). However, by the late 1950s, publications diminished. The profession was generally considered on its last gasp, an anachronism of the preantibiotic era. During the process of winning licensure, naturopathic medicine was defined formally by the various licensure statutes, but these definitions were legal and scope-of-practice definitions, often in conflict with each other, reflecting different standards of practice in different jurisdictions. In 1965 the U.S. Department of Labor’s Dictionary of Occupational Titles41 presented the most formal and widespread definition. The definition was not without controversy because it reflected one of the internally competing views of the profession, primarily, the nature cure perspective: Diagnoses, treats and cares for patients using a system of practice that bases treatment of physiological function and abnormal conditions on natural laws governing the human body. Utilizes physiological, psychological and mechanical methods such as air, water, light, heat, earth, phytotherapy, food and herbs therapy, psychotherapy, electrotherapy, physiotherapy, minor and orificial therapy, mechanotherapy, naturopathic corrections and manipulations, and natural methods or modalities together with natural medicines, natural processed food and herbs and natural remedies. Excludes major surgery, therapeutic use of x-ray and radium, and

13

the use of drugs, except those assimilable substances containing elements or compounds which are components of body tissues and physiologically compatible to body processes for the maintenance of life.41 This definition did not list drugs or surgery within the scope of modalities available to the profession. It defined the profession by therapeutic modality and was more limited than most of the statutes under which naturopathic physicians practiced,42 even in 1975, when there were only eight licensing authorities still active. 

MODERN NATUROPATHIC CLINICAL THEORY: THE PROCESS OF DEVELOPMENT Medical philosophy comprises the underlying premises on which a health care system is based. Once a system is acknowledged, it is subject to debate. In Naturopathic medicine, the philosophical debates are a valuable, ongoing process which helps the understanding of health and disease evolve in an orderly and truth-revealing fashion. Randall Bradley, ND43 After the profession’s decline in the 1950s and 1960s, a rebirth was experienced, more grounded in medical sciences and fueled by a young generation with few teachers. The profession’s roots were neglected out of ignorance, for the most part, along with a youthful arrogance. By the early 1980s, it was apparent that attempts to regenerate the progress made by Lust would require the creation of a unified professional organization and all which that entailed: accreditation for schools, national standards in education and licensure, clinical research, and the articulation of a coherent definition of the profession for legislative purposes, as well as for its own internal development. These accomplishments would be necessary to be able to demonstrate the uniqueness and validity of the profession, guide its educational process, and justify its status as a separate and distinct medical profession. In 1987 the newly formed (1985) American Association of Naturopathic Physicians (AANP) began this task of developing a unified professional organization under the leadership of James Sensenig, ND (president), and Cathy Rogers, ND (vice president). Four tasks were developed, and committees with specific chairs were delegated. One task was to pursue accreditation of our schools through governmental accreditation bodies, headed by Joe Pizzorno, ND. Another was to create a standard, national licensure examination, independent of the profession, headed by Edwin Smith, ND. A third was to create a peer-reviewed journal that the profession could use to demonstrate its rational basis, headed by Peter D’Adamo, ND. The fourth was a committee to head the creation of a new definition of naturopathic medicine headed by Pamela Snider, ND, and Jared Zeff ND, LAc. The “Select Committee on the Definition of Naturopathic Medicine” succeeded in its 3-year project, which culminated in the unanimous adoption by the AANP’s House of Delegates (HOD) of a comprehensive, consensus definition of naturopathic medicine in 1989 at the annual convention held at Rippling River, Oregon.44–46 The unique aspect of this definition was its basis in definitive principles, rather than therapeutic modalities, as the defining characteristics of the profession. In passing this resolution, the HOD also asserted that the principles would continue to evolve with the progress of knowledge and should be formally reexamined by the profession as needed, perhaps every 5 years.44–49 In September 1996 the AANP HOD passed a resolution to review three proposed principles of practice that had been recommended as

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additions to the AANP definition of naturopathic medicine originally passed by the HOD in 1989. These three new proposed principles were rejected, and the AANP HOD reconfirmed the 1989 AANP definition unanimously in 2000. The results of a profession-wide survey conducted from 1996 to 1998 on these three new proposed principles demonstrated that although there was lively input, the profession agreed strongly that the original definition was accurate and should remain intact. The HOD recommended that the discussion be moved to the academic community involved in clinical theory, research, and practice for pursuit through scholarly dialogue.50–54 This formed the basis for further efforts to articulate a clinical theory. AANP members stated in 1987 to 1989 during the definition process: “These principles are the skeleton, the core of naturopathic theory. There will be more growth from this foundation.”46 By 1997, this growth in modern clinical theory was evident. The first statement of such a theory was published in the AANP’s Journal of Naturopathic Medicine in 1997 in an article titled “The Process of Healing, a Unifying Theory of Naturopathic Medicine.”55 This article contained three fundamental concepts that were presented as an organizing theory for the many therapeutic systems and modalities used within the profession and were based on the principles articulated in the consensus AANP definition of naturopathic medicine. The first of these was the characterization of disease as a process rather than a pathological entity. The second was the focus on the determinants of health rather than on pathology. The third was the concept of a therapeutic hierarchy. This article also signaled the emergence of a growing dialogue among physicians, faculty, leaders, and scholars of naturopathic philosophy concerning theory in naturopathic medicine. The hope and dialogue sparked by this article were the natural next step of a profession redefining itself both in the light of today’s advances in health care and with respect to the foundations of philosophy at the traditional heart of naturopathic medicine. This dialogue naturally followed the discussions of the definition process and created a vehicle for emerging models and concepts to be built on the bones of the principles. The essence and inherent concepts of traditional naturopathic philosophy were carried in the hearts and minds of a new generation of naturopathic physicians into the 21st century— these modern naturopathic students and naturopathic physicians began to gather to articulate, redefine, and reunify the heart of the medicine. This new dialogue was formally launched in 1996, when the AANP Convention opened with the plenary session “Towards a Unifying Theory of Naturopathic Medicine,” with four naturopathic physicians presenting facets of emerging modern naturopathic theory. The session closed with an open microphone. The impassioned and powerful comments of the naturopathic profession throughout the United States and Canada engaged in the vital process of deepening and clarifying its unifying theory. Dr. Zeff presented “The Process of Healing: The Hierarchy of Therapeutics”; Dr. Mitchell presented “The Physics of Adjacency, Intention, Naturopathic Medicine, and Gaia”; Dr. Sensenig presented “Back to the Future: Reintroducing Vitalism as a New Paradigm”; and Dr. Snider announced the Integration Project, inviting the profession to engage in it by “sharing a beautiful and inspiring anguish—the labor pains of naturopathic theory in the twenty-first century. We know what we have done, and we know there is much more…The foundation is laid. We are ready now for development and integration.”56 Days later, in September 1996, the Consortium of Naturopathic Medical Colleges (now the American Association of Naturopathic Medical Colleges [AANMC]) formally adopted and launched the Integration Project, an initiative to integrate naturopathic theory and

philosophy throughout all divisions of all naturopathic college curricula, from basic sciences to clinical training. A key element of the project engaged the further development and refinement of naturopathic theory. The project was cochaired by Drs. Snider and Zeff from 1996 to 2003. Steering members from all North American naturopathic colleges participated and contributed.46 Methods included professional and scholarly research, expert teams, symposiums, and training. The result was the fostering of systematic inquiry among academicians, clinicians, and researchers concerning the underlying theory of naturopathic medicine, bringing the fruits of this work and inquiry into the classroom and into scientific discussion.57 The Integration Project sustained both formal and informal dialogue since its inception in 1996, which continues today through the Foundations of Naturopathic Medicine Institute. The work has engaged faculty and scholars of naturopathic philosophy in the United States, Canada, the United Kingdom, Australia, and many other countries where naturopathy is established or is professionalizing. It has also engaged institutional leaders and practicing doctors and faculty in all areas of the profession. Why? Naturopathic philosophy is deeply felt as the “commons” of naturopathic medicine: a place where the profession meets—one that is owned by all naturopathic physicians—that reflects, holds, and deepens the heart of naturopathic medicine. The philosophy of naturopathic medicine is the foundation and heart of naturopathic medicine and consists of its heritage, knowledge base, concepts, and knowledge codification; its clinical decision making; its integration and initiation of scientific research; and its public policy positions. The philosophy remains valid by evolving with the progress of knowledge, the progress of science, and the progress of the human spirit. It is for this reason medicine is seen as an art and a science. Because naturopathic philosophy engages the intuitively felt mission of nature doctors, it is vital that the profession periodically gathers to renew and revitalize progress regarding its unifying foundations. The Integration Project sparked a wide range of activities in all six ND colleges at that time, resulting in all-college retreats to share tools, retreats for training of non-ND faculty in naturopathic philosophy, integration of a basic sciences curriculum, expert-team revision of core competencies across departments ranging from nutrition to case management and counseling, development of clinical tools and seminars for clinic faculty, creation of new courses, and the integration of important research questions derived from naturopathic philosophy into research studies and initiatives.58 The latest effort, the Foundations of Naturopathic Medicine Institute and Project (textbook codification and symposia series; see www.foundationsproject.com) includes its development and presentation of the founding educational module on emunctorology, an essentially naturopathic science, during 2009 and 2010. This is a joint effort of faculty from several of our schools, led by Drs. Thom Kruzel, Rita Bettenberg and Stephen Myers. North American core competencies for naturopathic philosophy and clinical theory were developed by faculty representing all accredited ND colleges in a landmark AANMC retreat in 2000. The AANMC’s Dean’s Council formally adopted these competencies in 2000 and recommended that they be integrated throughout curricula in all ND colleges. These national core competencies included the process of healing theory, Lindlahr’s model, and the hierarchy of therapeutics (the therapeutic order).59,60 Finally, many meetings with scholars and teachers of naturopathic theory and other faculty and leaders—formal and informal—resulted in the further development and refinement of the hierarchy of therapeutics developed by Dr. Zeff in 1997. Drs. Snider and Zeff and worked closely with each other and then with other naturopathic theory faculty from AANMC colleges in a

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BOX 2.1  Working Definition of Naturopathic

Nutrition

Consensus Statement from Naturopathic Nutrition Faculty Retreat, Naturopathy and Nutrition Panel and Southern Cross University, June 2003, Preamble Naturopathic medicine is a distinct system of primary health care—an art, science, philosophy and practice of diagnosis, as well as treatment and prevention of illness. Naturopathic medicine is distinguished by the principles that underlie and determine its practice. These principles include the healing power of nature (vis medicatrix naturae), identification and treatment of the causes (tolle causam), the promise to first do no harm (primum non nocere), doctor as teacher (docere), treatment of the whole person, and emphasis on prevention. These principles give rise to a practice that emphasizes the individual and empowers him or her to greater responsibility in personal health care and maintenance. Definition Naturopathic nutrition is the practice of nutrition in the context of naturopathic medicine. Naturopathic nutrition integrates both scientific nutrition and the principles of naturopathic medicine into a distinct approach to nutritional practice. Core components of naturopathic nutrition are: Respect for the traditional and empirical naturopathic approach to nutritional knowledge The value of food as medicine An understanding that whole foods are greater than the sum of their parts and recognition that they have vitality (properties beyond physiochemical constituents) Individuals have unique interactions with their nutritional environments  Practice In the context of the definition, and with respect to the therapeutic order, the practice of naturopathic nutrition may include the appropriate use of the following: Behavioral and lifestyle counseling Diet therapy (including health maintenance, therapeutic diets, and dietary modification) Food selection, preparation, and medicinal cooking Therapeutic application of foods with specific functions Traditional approaches to detoxification Therapeutic fasting strategies Nutritional supplementation

series of revisions. Drs. Snider and Zeff collaborated in 1998 to develop the hierarchy of therapeutics into the “therapeutic order.” The therapeutic order was subsequently explored and refined through a series of faculty retreats and meetings, as well as through experience with students and through student feedback. A key finding of the clinical faculty at Bastyr University was the emphasis on the principle “holism: treat the whole person” and respect for the patient’s own unique healing order and his or her values as a context for applying the therapeutic order to clinical decision making.61 The therapeutic order, or hierarchy of healing, is now incorporated into ND college curricula throughout the United States, Canada, Australia, and New Zealand. For example, an important international outgrowth of the profession’s development of theory is the adoption of the unified “Working Definition of Naturopathic Nutrition” in June 2003 by the Australian naturopathic profession (Box 2.1). The 3-year project, fostered by Dr. Stephen Myers, brought together nutrition faculty from naturopathic medicine colleges throughout Australia. The project was cohosted by the Naturopathy and Nutrition Panel, an independent group of naturopaths and nutrition educators whose mission is to foster and support

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the development of the science, teaching, and practice of naturopathic nutrition, and the School of Natural and Complementary Medicine at Southern Cross University. The definition evolved over two retreats attended by more than 40 faculty members involved in teaching nutrition as part of a naturopathic medicine education. It commenced as a general agreement within the group that there was a real and distinct difference between conventional nutritional concepts and naturopathic nutritional theory. The general agreement was that the distinction between the two had been poorly defined to date and had been the source of dissonance between the naturopathic and science faculty within the colleges. The obvious next step was to define that difference to ensure that nutrition curriculum within naturopathic medicine colleges reflected the core elements of naturopathic nutrition. At the second retreat held in June 2003, the working definition was adopted with a recommendation that it be widely circulated within the naturopathic medicine profession to commence a dialogue aimed at both appropriate revision and broad adoption. This process created a much-needed consensus definition of naturopathic nutrition. This definition is based on the AANP defining principles and incorporates the therapeutic order theory. The AANP Definition of Naturopathic Medicine position paper was reviewed again in 2010 and reratified unanimously in 2011 by the AANP House of Delegates. “Prescription medications” were added to the single Treatment and Care section and both Naturopathic Practice sections in the 5-page paper (see www.naturopathic.org). In 2015 the World Naturopathic Federation, founded in 2015, published its first international survey results on naturopathic medicine’s core concepts and education in two white papers: The World Naturopathic Federation Report: Findings From the 1st World Naturopathic Federation Survey (2015) and WNF White Paper: Philosophies, and Principles, Theories (2017). The therapeutic order was reported in the top three (2015) and top five (2017) theory concepts utilized by the profession across the world. The results of the 2015 report stated that the AANP Definition of Naturopathic Medicine position paper and its six principles were widely accepted as written by professionalizing naturopaths in countries responding to the survey, at an average rate of 95%.62–65 

A THEORY OF NATUROPATHIC MEDICINE Standard medicine, or biomedicine, has a simple and elegant paradigm. Simply stated, it is “the diagnosis and treatment of disease.” In practice, this statement contains several assumptions. One assumption is that illness can be understood in terms of discrete diseases (i.e., human illnesses can be divided into identifiable entities, such as measles or specific forms of cancer, etc.). The next assumption is that “cure” is the elimination of the disease entity. The third assumption is that this is accomplished by the evidence-based application of pharmaceuticals, surgeries, or similar treatments to eliminate, palliate, or suppress the entity and its symptomatic expressions. These are so obvious that they are not commonly considered. They form the background thinking in medical decision making: “identify and treat the disease.” The elegance of this model, and the science behind it, has taken standard medicine to its highest point in history as a reliable vehicle to ease human illness, and its application has saved countless lives. The understanding of the physician, at least about the nature of pathology, has never been as complete as now. However, illness has a near-infinite capacity to baffle the physician. New diseases arise, such as Legionnaire’s disease, human immunodeficiency virus/acquired immune deficiency syndrome, and Lyme disease, and shifts occur in disease focus, such as the shift between 1900 and 2000 from acute infection to chronic illness as the predominant cause of death.66

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Beyond these obvious changes, even with the current depth of understanding, the standard medical world often lacks the ability to effectively understand and cure chronic disease, and treatment tends to become a task of the management of symptoms and the attempt to reduce long-term damage and other consequences rather than actual cure of the illness. So, even representing an apex of human achievement as it does, standard medicine is not without its weaknesses. Its greatest weaknesses include its relatively high cost,67 its tendency to create iatrogenic disease,67 and its inability to cure chronic illness as easily as it once cured pneumonia with penicillin or tuberculosis with streptomycin. Compounding the problem is the growing prevalence of antibiotic-resistant infections.68,69 Part of the reason for the failures within biomedical science is its mechanistic basis. Breaking the body down to its constituent parts has led to a fundamental ignorance of and disrespect for the wholeness of the individual, the natural laws of physiology governing health and healing, and particularly for all things spiritual (the transpersonal domains). Inherent in the dictum—diagnose and treat the disease—is the general neglect of the larger understanding that disease is a process conducted by and within an intelligent organism that is constantly attempting to heal itself, with disease manifestations often being expressions of this self-healing endeavor. As noted by Pizzorno et al.,70 this intelligent organism strives for optimal function and health. Human beings “are natural organisms, our genomes developed and expressed in the natural world. The patterns and processes inherent in nature are inherent in us. We exist as a part of complex patterns of matter, energy, and spirit. Nature doctors have observed the natural processes of these patterns in health and disease and determined that there is an inherent drive toward health that lives within the patterns and processes of nature.” The uniqueness of naturopathic medicine is not in its therapeutic modalities or the “natural” alternatives to the drugs and surgeries of standard medicine. It is the clinical theory that governs the selection and application of these modalities, captured in the unifying definition adopted in 1989 and expressed more specifically in the continuing articulation of clinical theory. That is, it is the way the naturopathic physician thinks about illness and healing. The first element of this theory is based on the first defining principle: vis medicatrix naturae. It is based on the understanding that disease can be seen as a process and an entity. One can analyze the process of illness and derive some understanding. However, to do this, one needs to examine the assumptions underlying this concept. The governing assumptions of standard medicine are principally that diseases are entities and that drugs and surgery can eliminate these entities from the suffering person. These are not the governing assumptions of naturopathic medicine.

Illness and Healing as Process Naturopathic medicine can be characterized by a different model than “identify and treat the disease.” “The restoration of health” would be a better characterization. Naturopathic physicians adopted the following elegantly brief definition of naturopathic medicine in 1989 in an AANP position paper: “Naturopathic physicians treat disease by restoring health.”45 Immediately, a significant difference is made clear: standard medicine is disease based; naturopathic medicine is health based. Although naturopathic medical students study pathology with the same intensity and depth as standard medical students, as well as its concomitant diagnoses, the naturopathic medical student learns to apply that information in a different context. In standard medicine, pathology and diagnosis are the basis for the discernment of the disease “entity” that afflicts the patient, the first of the two steps of identifying and destroying the entity of affliction. In naturopathic medicine, however, disease is seen much more as a process than as an entity. Rather

The Process of Healing Optimal health

Normal health Disturbing factors Disturbance of function

Discharge Process

Reaction (inflammation, fever, etc.)

Chronic reaction

Degeneration (ulceration, atrophy, scar, paralysis, tumor, etc.) Fig. 2.1  The process of healing. Copyright 1997. (Used by permission. Jared L. Zeff, ND, LAc.)

than viewing the ill patient as experiencing a “disease,” the naturopathic physician views the ill person as functioning within a process of disturbance and recovery, in the context of nature and natural systems. Various factors disturb normal health. If the physician can identify these disturbances and moderate them (or at least some of them), the illness and its effects abate. As disturbances are removed, the body can improve in function, and in doing so, health naturally improves. The natural tendency of the body is to maintain itself in as normal a state of health as is possible—this is the basis of homeostatic principles.71 The role of the physician facilitates this self-healing process. The obvious first task of the naturopathic physician, therefore, is to determine what is disturbing the health so that these causative elements may be ameliorated. Disease is the process whereby the intelligent body reacts to disturbing elements. It employs such processes as inflammation and fever to help restore its health. In general, one can graph this process simply, as in Fig. 2.1. 

The Naturopathic Model in Acute Illness One can see “illness as process” most easily in the common cold. Within standard medical understanding, the common cold is caused by a virus, from among a family of pathological viruses that can infect a person. The immune system responds, developing appropriate antibodies, which eventually neutralize the virus. There is no “cure” yet discovered, except time. Medications are used to ameliorate the symptomatic experience: aspirin or acetaminophen for fever, decongestants to dry the mucus discharge, and so forth. These measures are not cures; they reduce the symptomatic expression of the “cold” but often lengthen the process. In naturopathic medicine, the cold is seen not as a disease entity but as part of a fundamental process whereby the body restores itself to health. If the virus were the sole cause of the common cold, then everyone who came into contact with a sufficient dose of the virus would get the cold. Obviously, this does not happen. Susceptibility factors include immune competence, fatigue, vitality, genetics, and other host factors.72 The virus enters a milieu in which all these factors affect the process. Once the virus enters the system, and if it overcomes resistance factors (Box 2.2), one begins to see disturbance of function, as illustrated in Fig. 2.1. One does not feel quite right. One may

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BOX 2.2  Scientific Considerations: The

BOX 2.4  Scientific Considerations: The Role

Once inside the body, the rhinovirus binds to cellular receptors (primarily the intercellular adhesion molecule-1 [ICAM-1]) or to the low-density lipoprotein (LDL) receptor. The viral particles are then internalized and begin to take over the cellular machinery to produce intact virions.72,103 At this stage, the body can sometimes mount an adequate defense via cell-mediated immunity to overcome the viral incursion. If we have been previously exposed to the virus, the body’s humoral immune response will rapidly produce antibodies to the viral protein, which can also lead to eradication of the microbe. These two immune responses explain why some individuals may develop the full condition, whereas others will shake off the exposure within a few hours. If the viral load overcomes the body’s innate defenses, the virus replicates unabated. In the process of replication, the virus not only disrupts the cellular mechanisms but also damages them as well by infecting the surface epithelium and the macrophages104 and fibroblasts.105 Naturopathic physicians are interested in the factors that lead to greater immune competence and health restoration through the process of healing and the health practices that support it. French physiologist Claude Bernard (1813–1878) said that the inner terrain or “milieu interieur” was the cause of disease, not the microbes; this concept underpins the naturopathic approach.

Environmental and lifestyle disturbances are a profound driver in the naturopathic model of health. The scientific evidence is now irrefutable that the national and global burden of chronic disease is highly dependent on modifiable behavioral factors. In a recent study of the causes of death, it was found that tobacco, poor diet and lack of physical activity, alcohol and drug use, toxic agents, and vehicular and firearm incidents were the leading actual causes of death.76 Other factors included frank malnutrition (as opposed to poor nutrition), unsafe sexual practices, and poor sanitation.77,78 It has been definitively shown, for example, that diet and lifestyle changes can prevent some forms of diabetes101,102 and other chronic diseases142,143 that are leading causes of death in the United States.76,101,102

Immune Response and Resistance Factors

BOX 2.3  Scientific Considerations: Consequences of Suppressing the Body’s Response Current research shows that future pathologies may be linked to “suppression” of early rhinovirus infection. These include childhood asthma, adult asthma, and chronic obstructive pulmonary disease (COPD).106,107 Individuals with asthma are known to have subtle deficiencies in production of type I and type III interferon (IFN),108,109 indicating that for some asthma patients, early exposure to the rhinovirus predisposes them to asthma, and that the suppression of the normal response may be critical in the future development of asthma. With these effects in mind, the naturopathic physician does not look solely at the virus as a pathogenic entity but also seeks to determine how the patient responds to the virus, thereby determining the most reasonable approach to aiding the patient’s natural responses and moderating the patient’s long-term health strategies. Suppression of the body’s natural responses is avoided. The long-term use of corticosteroids is a prime example of suppression and its consequences.137,140

begin to get a sore throat, the first inflammatory reaction, occurring at the point of entry of the virus into the body. The immune factors described may overcome the virus at this point, may be insufficient, or may be suppressed. All of this is mutable to some extent and is affected by host factors, such as nutritional status and fatigue, and can be influenced by taking immune tonics, vitamin C, and other supplements. To the individual with the condition, the “cold” may proceed into a general state of fatigue and inflammation, possibly fever followed by mucus discharge, cough, and other symptoms, as the body processes and responds to the virus and its effects; eventually, the body overcomes it and eliminates the results. In the naturopathic model, the cold is not understood so much to be a separate disease entity but a general and fundamental process of disturbance and recovery within the living body. It is a method whereby the body restores itself after a sufficient amount of disturbance accumulates within the system. This is why the cold has no “cure.” It is the cure for what ails the body. In the naturopathic model of health, it is the support of this “adaptive response”—the restoration of balance that is the central point—through which the process is the “cure” (Box 2.3).

of Environment in Chronic Illness

The early naturopathic philosophers and clinicians predicted that the treatment of acute disease by suppressing symptoms (discussed in more depth later in the chapter) would result in more chronic disease. The current disease burden in the Western world certainly confirms this century-old prediction. 

The Naturopathic Model in Chronic Illness Chronic illness arises, in general, when any or all of three factors occur: 1. The disturbing factors persist, such as a chronically improper diet, which continues to burden the body cumulatively, as the digestive processes slowly weaken under the stress of the improper or inadequate diet. 2. The reactive potential is blocked or suppressed, often by drugs, which interfere with the capacity of the body to process and remove its disturbances. 3. The vitality of the system is insufficient, or has become too overwhelmed, to mount a significant and sufficient reaction. Again, as Lindlahr stated in Nature Cure, Chapters 2 and 4, disease is caused by one or more of the following as a result of violating nature’s laws of healthy living: Lowered vitality Abnormal composition of blood and lymph Accumulation of morbid matter and poisons As any of these factors either continue to accumulate and disturb function or reduce the ability of the body to purge the disturbance, the body slides into a chronic, weakened reactive state, with possible episodes of intermittent reaction, and is perceived to be in a persistent chronic illness. Ultimately, as function is sufficiently disturbed, structures or functions are damaged, and chronic inflammation becomes ulceration or scar tissue formation. In terms of the allostatic model, the balance has been disrupted, and there is no more adaptive potential. Atrophy, paralysis, or even tumor formation73–75 may occur. All of this is the body manifestly doing the best it can for itself in the presence of persistent disturbing factors and with respect to the limitations and range of vitality influenced by the constitution, psycho-emotional/spiritual state, and genotype of the person and his or her surrounding environment (Boxes 2.4 and 2.5). Reversal of this overwhelmed condition is rarely accomplished by medicating the pathological state. This often results in the control of symptoms but with the persistence of the illness while ideally controlling its more dangerous aspects using higher force interventions, such as pharmaceutical drugs and surgical intervention. Reversal is more likely accomplished by identifying and ameliorating the disturbance and, as necessary, strengthening or supporting the individual response or reactive potential. The first step in this process is to identify and reduce disturbing factors. 

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BOX 2.5  Scientific Considerations: Chronic

Illness and the Adaptive Response

Regarding the responses of an overwhelmed or chronically disturbed organism, it has been argued recently that the anemia of chronic disease is an adaptive biological response rather than a harmful disorder and is associated with a number of chronic states.92 Citing a number of studies, it was also argued that it was the treatment of the anemia of chronic disease among critically ill patients and those with renal failure and cancer (e.g., breast cancer and head and neck cancers) that was associated with the greater mortality. The U.S. Food and Drug Administration issued a warning against the use of erythropoiesis-stimulating agents in those cancer patients not undergoing chemotherapy or radiation therapy.143 States where the normal compensatory mechanisms become overwhelmed or suppressed (reducing the reactive potential of the body) include states of chronic oxidative stress144 and inflammatory processes.145,146 It is not, however, solely a matter of an overwhelmed or chronically disturbed organism that is critical to the process of disease progression. Adaptive responses are also of vital importance to the development of chronic disease. Research has shown that these evolutionarily preserved adaptive mechanisms of physical activity, insulin sensitivity, and fat storage are essential in the prevention of chronic disease states.141,142 In the development of type 2 diabetes, for example, there is increasing evidence that it is the individual’s maladaptation to lack of physical activity that appears to lead to decreased insulin sensitivity and increased fat storage, which can then lead to a plethora of chronic diseases, many characterized by states of chronic inflammation147 and oxidative stress. Continuing basic and clinical studies indicate that many of the processes currently regarded in mainstream medicine as harmful have been evolutionarily retained to provide an adaptive advantage.148,149 The Harvard Health Letter recently published an article describing inflammation as part of the “Unifying Theory of Disease”150 giving support to the argument that inflammation is crucial in both health and disease and that chronic diseases arise when the inflammatory process occurs without appropriate control. The allostatic model also provides a theoretical basis for naturopathic clinical theory. The allostatic model describes the process of achieving stability (homeostasis) through changes in the homeostatic “set points” or control boundaries.82–85 Homeostasis, the maintenance of stability in biochemical and physiological processes, is essential for life—and allostasis, the “resetting” of the homeostatic “set points,” is essential for the maintenance of homeostasis. As it develops through the various iterations of researchers and clinicians, the model emphasizes the need to look beyond the current linear-reductionist model of disease and toward a more holistic and balanced approach to disease conditions. The adaptive response of the organism to insult or frank structural damage is a concept that also has support outside naturopathic medicine. For example, Schnaper et al.151 described a conceptual framework for progressive kidney disease where the initial disease develops through an injury of some nature that provokes a cellular response as an adaptation to the original injury. Where this cellular response is effective, no progressive kidney disease may ensue. If, however, there is a maladaptation, these attempts at self-repair may lead to progressive loss of nephrons and chronic kidney disease.

THE DETERMINANTS OF HEALTH To reduce the disturbance, one must identify the disturbance. In standard medicine, the first step is to identify the pathology, which is then treated. In naturopathic medicine, one must come to understand what is disturbing the health. To do this, the physician needs to understand what determines health in the first place. The physician can then evaluate the patient in these terms and come to understand what is disturbing the natural state of health. Such a list could be created by any doctor, certainly any naturopathic physician. The authors propose the use of the list in Box 2.6.

Some of these determinants have been discussed—those modifiable behavioral factors such as drug and alcohol use, poor diet or frank malnutrition, lack of physical exercise, environmental and socioeconomic factors, and unsafe sexual practices76–79 (Box 2.7). Many of these behavioral factors have major psychological and spiritual components, and the effect can be increased stress on both the individual and the family, with all its attendant consequences.79–81 The naturopathic physician evaluates the patient with these areas in mind, looking for aspects of disturbance, first in the spirit and most generally in diet, digestion, and stress in its various aspects. In this evaluation, the naturopathic physician brings to bear a body of knowledge somewhat unique to naturopathic medicine to evaluate not solely in terms of pathological entity but also in terms of normal function and subclinical functional disturbance (Box 2.8). By locating areas of abnormal function or disturbance, the naturopathic physician acts or recommends ways to ameliorate the disturbance. As disturbing factors or insults to the system are reduced, the natural tendency of the system is to improve and optimize its function, directing the system back toward normalcy, or homeostasis. In more conventional medical terms, this is one of the fundamental concepts of the allostatic model.80,82–85 In naturopathic thinking, this is the removal of the obstacles to cure, which allows the emerging action of the vis medicatrix naturae, the vital force, the healing power of nature. This is the first step in the hierarchy of healing and what naturopathic physicians may call the overarching model in the clinical theory (the process of healing) of naturopathic medicine: the therapeutic order. This process can be seen in the naturopathic model of healing in Fig. 2.1. 

THERAPEUTIC ORDER AND NATUROPATHIC ASSESSMENT The Assessment Order: Components of a Vitalistic Assessment of Illness, Healing, and Health One thing I have learned in TCM, is that the assessment part implies the treatment, because the treatment is to balance what is imbalanced. Christy Lee Engel ND, Lac, Bastyr University, 2014 The assessment order is a set of prioritized components of a vitalistic naturopathic assessment of the patient based on, or dictated by observations of the • nature, • locus, or • center of gravity of the degenerative (disease) process. This degenerative disease process is evaluated in the context of natural health and healing systems, which interconnect • mind, body, and spirit; • the natural, cultural, and socioeconomic environments; • our heredity, and • how we live. These components have been recognized from ancient times through the present.86 Inclusive of conventional pathological evaluation, the naturopathic assessment order is a guideline to identifying and assessing various types, levels of, and priorities in the underlying causation of degenerative and dysfunctional conditions. The assessment order provides an ordered, nonrigid, dynamic framework (leading to the therapeutic order) for gauging the “center of gravity” of the disease process (the most efficient level at which to intervene to engage the patient’s healing response). By carefully assessing the status of the patient’s health and vitality and identifying components currently contributing to the disease process, the underlying causes become evident. These components

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BOX 2.6  Naturopathic Medicine Determinants of Health, Factors That Influence Health Inborn Determinants Genetic makeup (genotype) Intrauterine/congenital factors Intrauterine influences: maternal nutrition, health, and lifestyle Maternal exposures: drugs, toxins, illnesses, viruses, psycho-emotional Constitution: determines susceptibility  Disturbances/Disturbing Factors Illnesses: Patho-biography Medical interventions (or lack of) Physical and emotional exposures, stresses and trauma Toxic and harmful substances Trauma (physical/emotional) Toxemia Addictions Environmental disturbances, stress: environmental, physical, emotional  How We Live—Hygienic, Lifestyle, Psycho-emotional, Spiritual, Socioeconomic, and Environmental Factors Spirit Spiritual life/practice Self-assessment Relationship to larger universe (trust, consciousness, compassion)  Exposure to Nature/Environment Fresh air Clean water

Natural light Geography and ecosystem Exposure to natural systems, wild places, cycles  Diet, Nutrition, and Digestion Unadulterated food Optimal nutrition  Rest and Exercise Rest and sleep Recreation Exercise and movement Breath Vital force, vital reserve, energy Structural integrity  Socioeconomic Factors Loving and being loved Meaningful work Culture Community Government/public policy Environment Income and economic Health care (quality and access) Education

From Snider P, Zeff J, Myers S, DeGrandpre Z, et al. Course syllabus: NM5114, Naturopathic Clinical Theory. Seattle, WA: Bastyr University; 1997–2012.

BOX 2.7  Scientific Considerations:

Subclinical Inflammation and Chronic Illness It is becoming increasingly evident that many chronic diseases may have a long subclinical phase, most involving the inflammatory process. As mentioned, a chronic, subclinical inflammatory state has been linked to a number of disorders, including insulin resistance,152 obesity,153 vascular disease,154–157 hypertension,158 and aging.159

BOX 2.8  Scientific Considerations:

Determinants of Health Within Public and Community Health Concerns There exists an increasing consensus that Crohn’s disease and ulcerative colitis result from the combined effects of four important factors, none of which is individually sufficient to cause the disease. These four factors are the global changes in the environment, alterations in the microbiome of the intestine, multiple genetic factors, and aberrations or maladaptations in both the innate and adaptive immune systems.160–163 These four factors, considered to be vital to the development and the increased rates of irritable bowel disease, are quite similar to the determinants of health described in Box 2.6. This serves as a further example of the growing appreciation for the similarities (with important differences) between naturopathic medicine and public and community health.

are assessed for presence, absence, onset, triggers, depth, duration, and modalities and for physiological, psychospiritual, mental, biofield, organ system, and tissue targets. Components to be assessed include (1) determinants of health; (2) vitality; psychospiritual, mental, and energetic availability; and vital force; (3) physiological

and energetic systems; (4) structure and musculoskeletal components; (5) the pathology itself, its biochemistry, histology, and pathophysiology; and (6 and 7) the level and strength of specific, targeted, managerial, and higher-force interventions necessary for patient safety and reduction of suffering. Using the assessment order also engages the power of the patient– physician relationship: docere. “If the whole reason for the assessment is to develop a treatment plan [suitable to the patient’s safety and health recovery], that is one way to look at it. When we add the docere experience between physician and patient, then we add the complexity of the two systems, the intention of the physician, the energetic of the Vis—and we have a whole new dynamic in the assessment process, which itself begins to be the treatment process,” notes Christy Lee Engel ND, LAc. The case-taking and evaluation process thus begins the treatment process. It is the foundation of the doctor–patient relationship. Subjective and objective data contribute to both the pathological and the vitalistic assessment. The pathological assessment is viewed as partial although valuable information within the context of the entire vitalistic naturopathic assessment. The naturopathic assessment, in effect, places the disease process, its specific pathophysiology, and its staging within the broader context of the patient’s vitality, constitution, etiologic factors (never been well since), and underlying or root causes and leads to the level of intervention suggested by the therapeutic order. The patient’s story or patho-biography (Box 2.9) is an essential and powerful tool for making a complete naturopathic assessment. All information, subjective and objective (S, O), leads to the diagnosis and naturopathic assessment summary using the naturopathic assessment order (A) and to the treatment plan using the naturopathic therapeutic order (P). 

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The Naturopathic Medicine Assessment Order Components of a vitalistic assessment of illness, healing, and health I.  Evaluate Conditions for Health—Assess Naturopathic Medicine Determinants of Health Identify/assess inborn and constitutional factors (innate vitality and susceptibility)—genetics, epigenetics, constitution, elements, and individual perceptions and values. Identify/assess disturbing factors (obstacles to healing)—behavioral, hygienic, socioeconomic, environmental, psycho-spiritual, and cultural determinants. Identify/assess health-promoting factors—behavioral, hygienic, socioeconomic, environmental, psycho-spiritual, and cultural determinants.  II. Evaluate Vis Medicatrix Naturae: The Healing Power and Processes of Nature Assess vital force, vitality, energetic/biofield, and stage and status of healing/illness processes. Assess vital reserve and vitality. Assess spiritual state. Assess awareness, energy, and biofield. Assess vital force, direction, and intensity in healing versus illness process simillimum, signature, dual effect, chronobiology, minimum dose suppression, return of old symptoms/retracing Hering’s rules—direction of symptom progression Felt sense by patient of trust, energy, awareness, ability to love Assess impact of intention, healing practices, and healing interaction on healing response. Assess healing response—strength, direction, response versus reaction or crisis.  III.  Conduct a Functional Assessment of Physiological and Bioenergetic Systems Assess disturbances in physiological, energetic, and organ and cellular system functions and interrelationships—over-/underactivity, burden, obstruction, disorder, nourishment. Examples include neuroendocrine, digestive, emunctories, psycho-spiritual, and so forth.  IV.  Evaluate Structural Obstacles to Health Assess musculoskeletal and structural integrity. Assess need for nutrients, movement, and exercise to support musculoskeletal integrity.  V.  Conduct Pathological Assessment Assess symptoms, urgency, suffering, and potential for damage.  VI.  Assess Need, Risks, and Benefits of Highest-Force Interventions Patho-biography, follow-up, physical examination, signs, symptoms, lab imaging Copyright 2015. All Rights Reserved. Snider P, Zeff J, Pizzorno J, Myers, S, Sensenig J, Newman Turner R, Warren D, Kruzel T. Naturopathic Medicine Assessment and Therapeutic Order: The Naturopathic Medicine Assessment Order. The Foundations of Naturopathic Medicine—The Healing Power of Nature. The Holly Retreat 2015. Snoqualmie, WA: Foundations of Naturopathic Medicine Institute and Foundations of Naturopathic Medicine Project. http://www.foundationsproject.com. http://www.fnminstitute.org.

BOX 2.9  The Pathobiography In spite of the organic roots of our medical genesis, any [physician] must [not ] consider... illness purely as a material process of organic alteration. The integration of this illness in its anatomo-clinical aspect in the patient as a person enables us to discover the morbid dynamics underlying the pathological process. The “patho-biographic” case history assumes particular interest as it involves the entire psychic, emotional, affective life of the patient, his cravings, frustrations, achievements, anxiety to succeed, his perspectives. His patho-biographic past is no more than the process of psycho-physical adaptation of the individual to his circumstances and where physiopathological alterations are no more than the objective expression and the ultimate result of such adaptation.” Used with the permission of Dr. Eugenio Candegabe, Journal of the Society of Homoeopaths.

THERAPEUTIC ORDER The naturopathic medicine therapeutic order is a natural hierarchy of therapeutic intervention based on or dictated by observations of the nature of the healing process from ancient times through the present.86 The therapeutic order is a systematic approach to engaging the patient’s healing response by working with the order of effective

intervention inherent in the healing power and processes of nature. This order is simultaneously linear, holarchical, and recursive and functions as a multilayered, complex system powered by the vital force. It is either limited or increased in its efficiency by the level of the patient’s vitality. By removing obstacles to healing, establishing health-promoting factors (giving the body and spirit what it needs), and stimulating the vital force, vitality is increased, igniting the orderly self-healing processes of vis medicatrix naturae. Naturopathic physicians have long recognized (Box 2.10) that (1) the healing process is observable—a natural phenomenon (law of nature) seen consistently in health, healing, and illness (e.g., similar to laws of biology, physics, and regularities of other natural sciences); (2) “Naturopathic medicine recognizes this healing process to be ordered and intelligent” (Snider and Zeff et al., AANP House of Delegates, 1989, 2001, 2011). The principle vis medicatrix naturae guides the physician to ignite this ordered process by removing obstacles to healing (disturbing factors) and establishing a healthy internal and external environment (AANP 1989). This is accomplished by establishing individualized global health determinants that “treat disease by restoring health.” Less detailed therapeutic orders also exist in traditional Chinese, Tibetan, Ayurvedic, and Unani medicine theories. The therapeutic order is a natural ordering of the modalities of naturopathic medicine and their application. The concept is somewhat

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A Hierarchy of Healing: The Therapeutic Order

BOX 2.10  Nature’s Healing Order—Lindlahr Lindlahr referred to the vis medicatrix naturae as “the constructive principle in nature.” In 1914 he described the healing order this way: “The underlying causes of disease must be removed before we can cure chronic disease and bring about a normal condition of the organism…” the true healer is … the vis medicatrix nature which ... endeavors to repair, to heal and to restore all that the physician can do is to remove obstructions and to establish normal conditions within and around the patient, so that the healer within can do his work to the best advantage. . . . Though we cannot heal and give life, we can in many ways assist the healer within. We can teach and explain Nature’s Laws, we can remove obstructions and we can make the conditions within and around the patient more favorable for the action of Nature’s healing forces.” Lindlahr, H. Nature Cure. http://www.fulltextarchive.com/pdfs/ Nature-Cure.pdf. Nature Cure. 1913; 460, 532.

BOX 2.11  The Therapeutic Order: Hierarchy

of Healing

1. Establish the conditions for health. Identify and remove disturbing factors. Institute a more healthful regimen. 2.  Stimulate the healing power of nature (vis medicatrix naturae): the self-healing processes. 3. Address weakened or damaged systems or organs. Strengthen the immune system. Decrease toxicity. Normalize inflammatory function. Optimize metabolic function. Balance regulatory systems. Enhance regeneration. Harmonize with your life force.2 4. Correct structural integrity. 5. Address pathology: Use specific natural substances, modalities, or interventions. 6. Address pathology: Use specific pharmacological or synthetic substances. 7. Suppress or surgically remove pathology. The actual therapeutic order may change, depending on the individual patient’s needs for safe and effective care. The needs of the patient are primary in determining the appropriate approach to therapy. Acute and chronic concerns are both addressed using the therapeutic order.91 Acute concerns are addressed first to avoid further damage, risk, or harm to the patient. The point of entry for assessment and therapy is dependent on each patient’s need for effective and safe care, healing, and prevention of suffering or degeneration.2,91 From Zeff J, Snider P. Course syllabus: NM5131, Naturopathic clinical theory. Seattle, WA: Bastyr University; 1997–2005.

plastic, in that one must evaluate the unique needs, and even the unique healing requirements, of the specific patient or situation.87 However, the nature of healing dictates a general approach to treatment. In general, this order is listed in Box 2.11. An analogy for the therapeutic order in Australian integrative medicine is what is called the “softer option” model of patient care.88 This model recognizes that, given a choice, the patient will generally choose the softer option, provided that this does not limit a harder option if the softer option fails. By way of example, given a choice between an antibiotic and amputation for a minor cut finger, most people would choose the softer option. Expanding this range of choice to an herbal cream, antiseptic (herbal or nonherbal), and a Band-Aid; an antibiotic; or amputation, we develop a therapeutic order ranging from the

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softest option (the least force) to the hardest option (the higher-force intervention). The therapeutic order can be seen as a progression of therapeutic interventions that begins with this “softer option.”

Acute and Chronic Concerns As discussed previously, there is an inherent drive toward health that is observable within the patterns and processes of nature. The drive is not perfect. There are times when, unguided, unassisted, or unstopped, the drive goes astray, causing preventable harm or even death in patients; the constructive healing intention89 becomes destructive pathology. The ND is trained to know, respect, and work with this drive in both acute and chronic illness, using the therapeutic order, and to know when to wait or do nothing, act preventively, assist, amplify, palliate, intervene, manipulate, control, or even suppress using the principle of the least force.90 Acute and chronic concerns are both addressed and managed using the therapeutic order.91 Acute concerns are addressed first to avoid further damage, risk, or harm to the patient. The point of entry for assessment and therapy is dependent on each patient’s need for effective and safe care, healing, and prevention of suffering and degeneration.70,91 Naturopathic physicians avoid suppression of symptoms in acute circumstances unless necessary for patients’ well-being and safety. Instead, wherever possible, therapies for acute concerns use the least force (minimizing toxic side effects, suppression of natural functions, and physiological burdens) available to intervene effectively, healing or palliating as needed. The full range of modalities, from nutrition to homeopathy, botanical and physical medicine, hydrotherapy, counseling, prescriptive medication, and surgery, is available to the patient as the naturopathic physician works to apply the least force in providing effective preventive, acute, and chronic care.91 

Establish the Conditions for Health

Identify and Remove Disturbing Factors If one understands health to be the natural state and “disturbance” the original culprit, then identifying and reducing disturbance is the obvious first step, unless there is immediate danger to life or limb, in which case acting to reduce suffering and preserve life or limb is paramount. In most chronic disease, neither is immediately threatened. This understanding dictates the primary treatment goal the physician must attend to: the identification and amelioration of those factors disturbing health, especially factors that most disturb health (inappropriate diet, excessive stress, and spiritual disharmony). To understand what disturbs health, one must understand what determines health. The naturopathic physician evaluates a patient with reference to the determinants of health to discover wherein the patient’s health is disturbed. In this step, the physician is essentially removing the obstacles to cure and allowing the vis medicatrix naturae to do its work. Among these many possibilities, the most significant are attitude, diet, digestion, psychological and other stressors, and what might be called “spiritual integrity.” Humans have a transpersonal dimension and can be seen as spiritual beings. Spiritual here is not defined by religion or belief in a deity or deities; it is that component of individuals that gives rise to their inner compass, their “joie de vivre” and their internal meaning of life, their core beliefs, and their values. Perceived in this way, it can be seen that many people in society are experiencing “spiritual crises.”92 Although the general purview of the physician is the body, that instrument cannot be separated from the spirit that animates it. If the spirit is disturbed, the body cannot be fundamentally healthy. Hahnemann, the brilliant and insightful founder of homeopathy, instructed physicians to attend to the spirit.93 Disturbance in the spirit permeates the body and eventuates physical manifestation. Physicians are responsible

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BOX 2.12  Scientific Considerations:

Toxemia Today

Using conventional medical terminology, disorders derived from environmental, dietary, and lifestyle factors are termed idiopathic environmental intolerances, multiple chemical sensitivities,98,164–166 or sometimes oxidative stress disorders.167–171 The terminology may be different, but each term describes the same symptomatology. Environmental toxins accumulate, and chronic inflammation increases. These exogenous and endogenous toxins and the lack of exercise stress the system further. The ketogenic diet to control epilepsy may be considered one example of the successful application of diet to control symptoms.172

for perceiving such disturbances and addressing them. At colleges of naturopathic medicine in Australia, the United Kingdom, and North America, faculty work with naturopathic medicine students to develop their ability to perceive the spiritual nature of an individual as a foundational skill in addressing the spiritual crises or fundamental needs that have a profound effect on health and well-being. Using this definition, both atheists and agnostics can be seen to have a spiritual aspect. This definition also removes spirituality from religiosity in a way that does not denigrate any individual religious belief, allowing the naturopathic clinician to explore this aspect as part of routine care. One of the oldest concepts in naturopathic medicine is the concept of toxemia. Toxemia is the generation and accumulation of metabolic wastes and exogenous toxins within the body. These toxins may be the results of maldigestive processes, intermediate metabolites, environmental xenobiotics, and colon bacterial metabolites, for example. These toxins become irritants within the body, resulting in the inflammation of tissues and the ultimate interference with normal biochemical processes.94 The maldigestive and dysbiotic95,96 origin of these internally and externally derived toxins is the result of an inappropriate diet, broad-spectrum antibiotics, and the effects of excessive stress on digestion.97 Eating a diet that cannot be easily digested or that is out of appropriate nutrient balance for the individual results in the creation of metabolic toxins in the intestines.95–98 Stress, causing the excessive secretion of cortisol and adrenaline, results in the decrease of blood flow to the digestive process, among other effects,80,82–85 which decreases the efficient functioning of digestion and increases the tendency toward maldigestion, dysbiosis, and toxemia. Physicians can now easily measure the degree of toxemia in various ways (urinary indican or phenol98). The older concept of toxemia,99,100 with scientific advances in its understanding91,99 (Box 2.12), may now be productively combined with an understanding of the newer concept of allostasis82–85 and the historical89,100 and reemerging discussion on the inflammatory component of many, if not most, chronic diseases. Spiritual disharmony, inappropriate diet, digestive disturbance, stress, and toxemia (leading to inflammation) are considered primary causes of chronic illness and must be addressed if healing is to occur. Beyond these, other disturbing factors must be discerned and addressed, whichever pertain to the individual patient.101,152–154,158,159,165–171 

Institute a Healthier Regimen As a corollary of the first step, once physicians have determined major contributing factors to illness, they construct a healthier regimen for the patient. Some disturbing factors can be eliminated, like inappropriate dietary elements.110,111 Others are a matter of different choices or living differently. The basics to consider are appropriate diet, appropriate rest and exercise, stress moderation, a healthy environment, and a sense of spiritual fulfillment.82,92,141,142,145,146,148

If this model is correct, these measures alone should result in enhanced health. The problem arises in knowing how to do these things. What is an appropriate diet? This is an area of considerable controversy. Physicians think about diet in many different ways. The goal of dietary improvement is to reduce the symptomatic consequences of the patient’s diet and provide optimal nutrition to the patient. The point here, regardless of how this is done, is that it is central and essential for fundamental health improvement. If the diet is not correct, if digestion is not appropriate, if nutrition is not adequate, the patient cannot appropriately function or improve, and the scene is potentially set for chronic inflammatory conditions and the resetting of the adaptive allostatic and homeostatic set points. If the diet and digestion are appropriate, the basis for improvement in other areas is enhanced. The same is true with these other fundamental elements, to which Lindlahr referred in the first element of his catechism, “return to nature”: exercise, rest, dress, and so forth.29 These have been expanded in the “determinants of health.” They create the basis for improvement. What this really means is to change the “terrain,” the conditions in which the disease has formed—not only to change but to improve the conditions so that there is less basis for the disease. Hahnemann addresses this on the first page of his Organon of Medicine.93 He identified four tasks for the physician: to understand the true nature of illness, “what is to be cured”; to understand the healing potential of medicines (whether they enhance or suppress function); to understand obstacles to recovery and how to remove them (the determinants of health); and to understand the elements that derange health and how to correct them so that recovery may be permanent.93 Changing and improving the terrain in which the disease developed is the obvious first step in bringing about improvement. This sets up the basis for the following elements to have the most beneficial effects. 

Stimulate the Self-Healing Mechanisms A certain percentage of patients will improve sufficiently simply by removing disturbing factors and establishing a healthier regimen. Most require more work. Once the patient is prepared, once the terrain is beginning to clear of disturbing factors, then one begins to apply stimulation to the self-healing mechanisms. The basis of this approach is the underlying recognition of the vis medicatrix naturae, the tendency of the body to be self-healing, the wisdom and intelligence within the system that constantly tends toward the healthiest expression of function, and the healing “forces” in the natural environment (air, water, light, etc.). The body heals itself. The physician can help create the circumstances to promote this. Then, as necessary, the physician stimulates the system. This also requires that attention be given to the patient’s emotional state of mind because the psychological condition of the patient is often of major importance.113,114 One of the best ways to do this is through constitutional hydrotherapy, as developed by Otis G. Carroll, ND, early in the past century. This procedure is simple, involving the placement of hot and then cold towels on the trunk and back, in a specific sequence (depending on the patient), usually accompanied by a sine-wave stimulation of the digestive tract. This is a dynamic treatment, simple, inexpensive, and universally applicable. It helps recover digestive function, stimulates toxin elimination, “cleanses the blood,” enhances immune function, and has several other effects. It moves the system along toward a healthier state.115 Exercise often achieves similar results. Many naturopathic modalities can be used to stimulate the overall vital force. More specific approaches to stimulation, although general in effect, are applied differently to each patient and have a less general effect than those previously mentioned. Homeopathy and acupuncture116–118 are often the primary methods of such stimulation. They add little to the system; they are not gross chemical treatments. They work with what is there, stimulating a reaction, stimulating function, and correcting disturbed patterns.

CHAPTER 2 

A Hierarchy of Healing: The Therapeutic Order

Each method helps move the system out of its disturbed state and, with the reduction of encumbrance, helps move it toward health. Finally, exposure to the patterns, rhythms, and forces of nature is a traditional part of naturopathic medicine and the tradition of nature doctors throughout the world. As previously noted, “We exist as part of complex patterns of matter, energy, and spirit,”2 and the natural progression of these patterns, and the drive toward health inherent in them, is a natural ally for the physician. Exposure to appropriate rhythms, patterns, and forces of nature strengthens vitality and stimulates the healing power of nature. 

Support Weakened or Damaged Systems or Organs Some systems or functions require more than stimulation to improve. Some organs are weakened or damaged (e.g., adrenal fatigue after prolonged stress), and some systems are blocked or congested (e.g., the hepatic detoxification pathways) and require extra help. This is where naturopathic physicians use their vast natural medicinary. Botanical medicines can affect any system or organ, enhancing its function, improving its circulation, providing specific nutrition, and stimulating repair. Glandular substances can be applied to a similar purpose. Plus, there are a growing number of evidence-based “nutraceuticals”— biological compounds that enhance metabolic pathways and provide specific substances to enhance metabolic function.119–130 Naturopathic physicians can also apply specific homeopathic medications, usually in the lower potencies, which act nutritively and can stimulate specific organs or functions. This method, generally referred to as drainage, can be used to stimulate detoxification of specific substances from the body in general or of specific organ systems or tissues. Dr. Pizzorno’s work in Total Wellness and The Toxin Solution131,132; the work of “functional medicine” leader Jeffrey Bland, PhD; and the Textbook of Functional Medicine by Jones90 exemplify the clinical strategies applied at this level of the therapeutic order. These strategies are used to restore optimal function to an entire physiological system (immune, cardiovascular, detoxification, life force, endocrine).131,132 One can also use specific exercises to stimulate or enhance organ health. Some systems of yoga and qi gong are organ specific. Specific applications of hydrotherapy and other physiotherapy systems can be applied to enhance the function of organs or tissues. It has been the clinical experience of many naturopathic physicians that these methods, combined with an appropriate diet and a healthier regimen, along with constitutional hydrotherapy, appropriate homeopathy, and acupuncture, bring most health problems back to normal, without negative consequence, rapidly, efficiently, and permanently. 

Address Structural Integrity Many structural problems result from generalized stress of some kind on internal systems. For example, midback misalignment or discomfort (T1–T12) is often found associated with a history of underlying stress on the digestive organs, the enervation of which originates at those spinal segments. One can manipulate the vertebra back into proper alignment or massage contracted musculature, but until one corrects the underlying functional disturbance, there will be a tendency to repeated structural misalignment. In some circumstances, the singular problem may be simply structural disintegrity. One may have fallen or been hit in some fashion and simply needs the neck manipulated back into proper alignment and the surrounding soft tissue relaxed. There may be no dietary error or other disturbance aside from the original injury, and correction requires only simple manipulation or therapeutic massage. This is an example of the flexibility of the therapeutic order concept. In this case, first-order therapeutics manipulate the cervical spine or relax chronically contracted muscles. Usually,

23

however, the problem of structure is part of the larger problem, and such intervention becomes a fourth-order therapeutic.70 Reintegrating structure can occur in many ways, one of which is the method of “bone cracking” known to the ancient Greeks and Chinese and probably all other ancient healing cultures. However, there are nonforce manipulative systems that include many modalities of therapeutic massage. Some systems of exercise are designed to reintegrate and maintain normal structural relationships. Any of these might be appropriate to a specific patient. By approaching the problem in the context of the therapeutic order, one can expect structural corrections to be required only occasionally and for the results to be more or less permanent. 

Address Pathology: Use Specific Natural Substances, Modalities, or Interventions Having gone through the first four steps of this therapeutic hierarchy, most patients improve. The improvement is based on the sound footing of the underlying correction or removal of fundamental causative elements. It is also based on the intrinsic nature of the body to heal itself using the least possible force. Most pathology improves or disappears under these circumstances, but sometimes it is necessary to address pathology. This may be the case because the particular pathology may be threatening to life or limb. Acting on this threat is imperative. It can often be done with naturopathic means, directed specifically against the pathology. Biochemical or genetic individuality also can demand an emphasis at this level of intervention. One of the major conflicts in naturopathic medicine is that some practitioners find it expedient to diagnose and treat pathology (the standard medical model) rather than pursue a naturopathic model of practice. This approach tends to be less satisfying and less productive of the most elegant outcomes and the long-term continued health of the patient. It also reduces the capacity of the physician to treat, such as in cases where there is no evidence-based treatment for the pathology in question, or where there is no clear diagnosis (i.e., no distinct pathology to treat). This approach is increasingly referred to as “green allopathy.” However, the vast body of knowledge that naturopathic education presents in this arena makes such an approach seductive, especially in a culture that more or less expects, supports, reinforces, and pays for a biomedical (“allopathic”) approach to diagnosis and treatment. It is easy to do this. The culture is accustomed to this model and often expects to encounter this in the naturopathic physician’s office. In some states, such as Oregon, Washington, and Arizona, where the naturopathic formulary includes most antibiotics and many pharmaceutical drugs, one can practice almost without distinction from a medical doctor. The typical naturopathic formulary is often sufficient to prescribe on a strictly pathological basis. The problem with this is that it is generally not as effective, especially in the treatment of chronic disease. The value of naturopathic medicine in our culture is not that naturopathic physicians can function almost like medical doctors, with a “natural” formulary instead of drugs. It is that they offer a fundamentally different approach, one based on the restoration of health rather than the treatment of disease. Given all of this, it still may be useful to directly address the pathological entity or its etiology.112,133-136 When treating an antibioticresistant infection, for example, it may be useful to apply botanical medicines with specific antibiotic properties, along with immune tonics and the more fundamental steps of this therapeutic hierarchy. In difficult cases, such as many cancers, using agents that have specific, pathology-based therapeutics may be an essential element of comprehensive treatment. The naturopathic formulary provides a vast and increasing number of such options. One advantage of such treatment

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Philosophy of Natural Medicine

is that, in general, when applied by a knowledgeable practitioner, it rarely adds more burden or toxicity to the system. Naturopathic pathology-based treatments still follow the dictum “do no harm.” 

generally avoid suppression, which is a primary way in which physicians can inflict harm, even with the best of intentions. 

Address Pathology: Use Specific Pharmacological or Synthetic Substances

THEORY IN NATUROPATHIC MEDICINE

About 800,000 medical doctors and osteopathic physicians in the United States are trained in the science of pathology-based treatment, using pharmaceuticals and surgery, for example. There are times when such an approach is necessary to preserve life, limb, or function. Although some naturopathic physicians, by training and by statute, may prescribe pharmaceuticals or perform minor office procedures and surgeries, naturopathic physicians may also refer patients in need of such services to appropriate standard medical doctors (MDs) or medically trained osteopaths (DOs). In a growing number of states, NDs can legally provide an expanding range of prescription drugs. Although this is an important tool for the naturopathic primary caregiver, this privilege requires enhanced responsibility for the ND to prescribe those substances only as needed—and to thoroughly rely on applying the least force appropriate to effect recovery and protect patient safety. Both Dr. Lust (at the end of his life) and Dr. Bastyr recognized the need for NDs to have the ability to access, as needed, prescriptive medications and perform minor office procedures to function as primary caregivers. However, both admonished that the philosophy and principles of the medicine guide their judicious use—only as truly needed, based on the least force necessary to restore the patient to health. Naturopathic physicians are well trained in this regard and respect the necessity and utility of standard medical practice in appropriate situations. Some disagreement exists regarding which situations may be appropriate. The AANP has developed position papers to resolve some of these questions. In general, although recognizing the necessity of such treatment, most naturopathic physicians also recognize that such treatment often carries consequences that also must be addressed. 

Suppress Pathology Sometimes it is necessary, when there is a risk of harm to the patient’s health or tissue or to relieve suffering, to suppress pathology. Medical doctors are especially trained in this art and have powerful and effective tools with which to do this. Unfortunately, suppression, because it does not fundamentally remove or address essential causative factors (e.g., dietary error) often results in the development of other, often deeper disturbance or pathology. Because much pathological expression is the result of the actual self-healing mechanisms (e.g., inflammation), suppressive measures, in general, work in opposition to the vis medicatrix naturae. The result of suppression is that the fundamental disturbing factors are still at play within the person, still disrupting function to some extent, whereas the suppression reduces the symptomatic expression and resolution of disturbance. One simple example of this is the overuse of oral corticosteroidal anti-inflammatory and antihistaminic drugs in the treatment of acute asthma. This usually effectively opens the airways. However, prolonged use weakens the patient. If the treatment persists, the patient may become immune compromised or osteoporotic or can develop psychological disorders. These symptoms are part of the long-term effects of steroids.137 It may, of necessity, maintain breathing, but the long-term cost to the organism can be high. Suppression, although it may be lifesaving, often has serious consequences. With standard medical methods of care, the cure of chronic illness is often elusive. This is the benefit of the naturopathic approach: by taking a nonsuppressive course of action, based on sound physiological principles, one can often restore health without recourse to the potential damage of suppression. Naturopathic physicians, although recognizing the occasional necessity of suppressive approaches,

The therapeutic hierarchy is based on the observation of the nature of healing and the inherent order of the healing process. It is part of a unifying theory of naturopathic medicine, an outgrowth of the principles that underlie naturopathic thinking. It provides the physician with instructions that order the many therapeutic modalities used by the practice. The consensus definition of naturopathic medicine, adopted by the AANP in 1989, is a statement of identity, distinguishing naturopathic medicine from other systems of medical thought. Contained within it is a set of instructions regarding the practice of the medicine. The three concepts discussed here—“disease as process,” “the determinants of health,” and “the therapeutic order”—are an articulation of these instructions. They are presented as a clinical theory of naturopathic medicine. They have been crystallized, as is the definition, from the observation by nature doctors throughout time and across many traditions of the nature of health, disease, and healing. They provide the physician with instructions. These instructions include a procedure for thinking about human illness in such a way that one can approach its cure in an ordered fashion by understanding its process as an expression of the vis medicatrix naturae. It provides the framework for truly evaluating the patient as a whole being: spiritual, mental/emotional, and physical, rather than as a category of pathology. Plus, the theory of naturopathic medicine provides the physician a system for organizing and efficiently integrating the vast therapeutic array provided in naturopathic medicine. Ultimately, it satisfies Hahnemann’s observation of the ideal role of medicine, that “the highest ideal of cure is rapid, gentle and permanent restoration of the health … in the shortest, most reliable and most harmless way, upon easily comprehensible principles.”93 The roots of the observations that form this theory are traceable through the mid- and early 20th century, to the traditional theory of the 19th-century European nature cure, and to the roots and theories of traditional world medicines. Hippocrates’s writings on the vis medicatrix naturae form a foundation that historically underpins the development of this theory.138,139 Finally, it is observable across many traditional world medicines that various healing orders are described. Such structures hold implications for public and community health priorities and suggest the reprioritization of healthcare priorities and financing. Implications for public policy and the growing national disease debt invite exploration. Although this presentation is not comprehensive, the attempt has been made to demonstrate these roots, at least in some of their major articulations. The work presented here is a continuation of this historical process, which ultimately is driven by the true mission of the physician: to ease suffering and to preserve life. What Methods of Cure Are in Conformity with the Constructive Principle in Nature? Those methods which: Establish normal surroundings and natural habits of life in accord with Nature’s Laws. Economize vital force. Build up the blood on a natural basis, that is, supply the blood with its natural constituents in right proportions. Promote the elimination of waste matter and poisons without in any way injuring the human body. Arouse the individual in the highest possible degree to the consciousness of personal accountability and the necessity of intelligent personal effort and self-help.29

REFERENCES See www.expertconsult.com for a complete list of references.

REFERENCES 1.  See Chapter 5 for a more comprehensive and more fully documented— with some differences—history of naturopathic medicine. 2. Pizzorno J, Snider P. Naturopathic medicine. In: Micozzi MS, ed. The Fundamentals of Complementary and Alternative Medicine. New York: Churchill Livingstone; multiple editions. 3. Cody G. The history of naturopathic medicine. In: Pizzorno J, Murray M, eds. Textbook of Natural Medicine. New York: Churchill Livingstone; 1999. 4. Kirchfeld F, Boyle W. The Nature Doctors: Pioneers in Naturopathic Medicine. Portland, OR: Medicina Biologica; 1994. 5. Schramm A, ed. Yearbook of the International Society of Naturopathic Physicians and Emerson University Research Council. Los Angeles: International Society of Naturopathic Physicians; 1945. 6. Tribe W. Personal communication. National College Professional Survey. Portland, OR: National College of Naturopathic Medicine; 2008. 7. Wendel P. Standardized Naturopathy. Brooklyn, NY: Paul Wendel; 1951. 8. Kirchfeld F, Boyle W. Nature Doctors. East Palestine, OH: Buckeye Naturopathic Press; 1994. 9. Freibott G. Report Submitted to Lanso Cavasos, Secretary of Education. Washington, DC: U.S. Department of Education; 1990. 10. Spitler HR. Basic Naturopathy, a Textbook. New York: American Naturopathic Association; 1948. 11. Wendel P. Standardized Naturopathy. Brooklyn, NY: Paul Wendel; 1951. 12. Coulter H. Divided Legacy: A History of the Schism in Medical Thought. Washington, DC: Weehawken Book Company; 1973. 13. Engel GL. The need for a new medical model: a challenge for biomedicine. Science. 1977;196:129–136. 14. Lear L. Rachel Carson Biography. http://www.wilderness.net/index .cfm?fuse=feature0407. Accessed August 10, 2011. 15. Enrollment records. National College of Naturopathic Medicine. Accessed June 20, 2004. 16. Kirchfeld F, Boyle W. The Nature Doctors: Pioneers in Naturopathic Medicine. Portland, OR: Medicina Biologica; 1994. 17. Snider P. The future of naturopathic medical education—primary care integrative natural medicine: the healing power of nature. In: Cronin M, ed. Best of Naturopathic Medicine: Anthology 1996: Celebrating 100 Years of Naturopathic Medicine. Tempe, AZ: Southwest College of Naturopathic Medicine Publications; 1996. 18. Snider P. Integration project survey results: report to the AANMC dean’s council [Database]; 1999. 19. Standish L, Calabrese C, Snider P, et al. Naturopathic medical research agenda: report to NCCAM: Draft. 2004:5. 20. Tilden JH. Toxemia Explained: An Antidote to Fear, Frenzy, and the Popular Mad Chasing After So-Called Cures: The True Interpretation of the Cause of Disease, How to Cure Is an Obvious Sequence. Rev. ed. Denver: FJ Wolf; 1926. 21. Trall R. The True Healing Art. New York: Fowler & Wells; 1880. 22. Graham S. Greatest Health Discovery: Natural Hygiene & Its Evolution Past, Present & Future. Chicago: Natural Hygiene Press; 1860. 23. Kellogg J. Rational Hydrotherapy. 2nd ed. Philadelphia: FA Davis Co; 1903. 24. Kuhne L, Lust B. Neo-Naturopathy: The New Science of Healing or the Doctrine of the Unity of Diseases. Butler, NJ; 1917. 25. Kuhne L, Lust B. The Science of Facial Expression: The New System of Diagnosis, Based on Original Researches and Discoveries. Butler, NJ; 1917. 26. McFadden B. MacFadden’s Encyclopedia of Physical Culture. Vol. 5. New York: Physical Culture Publishing; 1920. 27. Rikli A. Die Grundlerhren der Naturheilkunde einschliesslich “Dia atmospharische Kure,” “Es werde Licht” und “Abschiedsworte” [The Fundamental Doctrines of Nature Cure including “the Atmospheric Cure,” “Let There Be Light” and “Words of Farewell”]. 9th ed. Wolfsburg, Germany: G. Rikli; 1911. 28. Tilden JH. Impaired Health: Its Cause and Cure—A Repudiation of the Conventional Treatment of Disease. 2nd ed. Denver: Tilden; 1921. 29. Lindlahr H. Nature Cure: Philosophy and Practice Based on the Unity of Disease and Cure. Chicago: Nature Cure Publishing; 1913.

30. Kneipp S. Thus Shalt Thou Live. Kempten, Bavaria: Koesel; 1889. 31. Kneipp S. My Water Cure. UK: Thorsons; 1979 (reprint of 1891 edition). 32. Kneipp S. My Will. Kempten, Bavaria: Koesel; 1894. 33. Trall RT. Hydropathic Encyclopedia: A System of Hydropathy and Hygiene. New York: Fowlers & Wells; 1851. 34. Rausse JH. Der Geist der Graffenberger Wasserkur. Zeitz: Schieferdecker; 1838. 35. Rikli A. Die Thermodiatetik oder das tagliche thermoelectrische Licht und Luftbad in Verbindung mit naturfemasser Diat als zukunftige Heilmethode. Vienna: Braumueller; 1869. 36. Thomson S. A Brief Sketch of the Causes and Treatment of Disease. Boston: EG House; 1821. 37. Beach W. A Treatise on Anatomy, Physiology and Health. New York: W. Beach; 1847. 38. Ellingwood F. American Materia Medica, Therapeutics, and Pharmacognosy. Evanston: Ellingwood’s Therapeutist; 1919. 39. Felter H. The Eclectic Materia Medica, Pharmacology, and Therapeutics. Cincinnati: John K Scudder; 1922. 40. Boyle W. The Herb Doctors. East Palestine, OH: Buckeye Naturopathic Press; 1988. 41. Dictionary of Occupational Titles. Vol. 1. 3rd ed. Washington, DC: U.S. Department of Labor; 1965. 42. Schram A. Acts and laws. In: Yearbook of the International Society of Naturopathic Physicians & Emerson University Research Council. Los Angeles: International Society of Naturopathic Physicians; 1945. 43. Bradley R. Philosophy of naturopathic medicine. In: Pizzorno J, Murray M, eds. Textbook of Natural Medicine. New York: Churchill Livingstone; 1985. 44. AANP House of Delegates Resolution. Rippling River, OR; 1989. 45. Select Committee on the Definition of Naturopathic Medicine, Snider P, Zeff J, co-chairs. Definition of Naturopathic Medicine: AANP Position Paper. Rippling River, OR: AANP; 1989. 46. Select Committee on the Definition of Naturopathic Medicine. AANP 1987–1989. Report submitted to AANP in 1988, final recommendation submitted to AANP House of Delegates Rippling River, OR; 1989. 47. Snider P, Zeff J. Personal letters and communications, 1987–1989. 48. Zeff J. Convention theme: “what is a naturopathic physician?” AANP Q News. 1988;3(1):11. 49. Snider P, Zeff J. Definition of naturopathic medicine: first draft. AANP Q News. 1988;3:6–8. 50. North American Association of Naturopathic Medical Colleges Integration Project Survey 1997–1999. Preliminary report. October 26, 1999. Snider P, Zeff J, co-chairs. Mitchell M, Bastyr University Integration Project Student Task Force Chair. Monwai M, database and research assistant. 51. Snider P, Zeff J. Integration Project Report on Survey Data and Proposed Principles of Naturopathic Medicine to the AANMC Dean’s Council; 1999. 52. The integration project update 2000: AANP house of delegates principles survey, presented by Mitchell M, IP student task force chair 1997–2000. Comments presented by Snider S, Zeff J, co-chairs integration project 1996–2000. Monwai M, database manager. Saunders F, data analyst. 53. O’Keefe M, Milliman B, Zeff J. Proposed New Principles of Naturopathic Medicine: Wellness, Least Force, Relieve Suffering. Submitted to the AANP House of Delegates; 1996. 54. Resolution introduced in House of Delegates regarding new principles: passed 2000 AANP convention, Seattle, WA. The House of Delegates recommended that the discussion be moved to the academic community involved in clinical theory and practice for development. 55. Zeff J. The process of healing: a unifying theory of naturopathic medicine. J Naturopath Med. 1997;1:122–126. 56. Snider P, Zeff J, Sensenig J, et al. Towards a Unifying Theory of Naturopathic Medicine. AANP Plenary Session. Portland, OR: AANP; 1996. 57. Snider P. Integration project: timeline, scope of work, goals, methods. Proposal adopted by CNMC 1996, readopted by AANMC 1997–1998. 58. CNME report from Bastyr University. Standard XI and appendices: curriculum; 1999. 59. AANMC Dean’s Council minutes and correspondence; 2000. 60. Snider P, Downey C. Co-chairs. Invitation Letter, Supporting Information, Agenda, Minutes, Tools and Materials. AANMC Integration Project Retreat for Naturopathic Philosophy and Clinical Theory Faculty, Basic Sciences Chairs and Clinic Directors; 2001:20–21.

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FURTHER READINGS Festa A, et al. Chronic subclinical inflammation as part of the insulin resistance syndrome: the insulin resistance atherosclerosis study (IRAS). Circulation. 2000;102(1):42–47.

Kiecolt-Glaser JK, McGuire L, Robles TF, et al. Emotions, morbidity, and mortality: New perspectives from psychoneuroimmunology. Ann Rev Psych. 2002;53:83–107. Shekelle PG, Adams AH, Chassin MR, et al. Spinal manipulation for low-back pain. Ann Int Med. 1992;117(7):590–598. Woods JA, Vieira VJ, Keylock KT. Exercise, inflammation, and innate immunity. Immunol Allergy Clin North Am. 2009;29(2):381–393. Yetley EA. Multivitamin and multimineral dietary supplements: definitions, characterization, bioavailability, and drug interactions. Am J Clin Nutr. 2007;85(1):S269–S276.

3 The History of Naturopathic Medicine: Origins and Overview George W. Cody, JD, MA, and Heidi Hascall*, MA

OUTLINE Introduction, 25 Brief History of Early American Medicine With an Emphasis on Natural Healing, 26 Medicine in America: 1800–1875, 26 The American Influence, 28 The Beginnings of “Scientific Medicine”, 30 The New “Sects”, 31 The Founding of Naturopathic Medicine, 31 Benedict Lust, 31 Introduction, 32 The Principles, Aim, and Program of the Nature Cure System, 33 Life Maltreated by Allopathy, 34

What Is Life?, 34 The Naturopaths, 34 The Program of Naturopathic Cure, 34 The Germanic Influence, 35 The Convergence With American Influences, 36 Early-20th-Century Medicine, 38 The Metamorphosis of Orthodox Medicine, 38 The Halcyon Years of Naturopathy, 38 The Emerging Dominance of American Medical Association Medicine, 40 The Modern Rejuvenation, 44 The 21st Century Awaits, 46

Editors’ Note: This is the first of two chapters comprehensively presenting the origins and evolution of naturopathic medicine. Quotes from key historical figures are used extensively in both chapters to illustrate how the ideas of naturopathic medicine originated and evolved. One challenge with this approach is that the language use and terminology more than a century ago are somewhat different from the current vocabulary. In addition, these pioneers were limited by the very early stages of the biological sciences because rigorous research into physiology and pathology was just beginning. Thus, from the modern perspective, some ideas may seem quaint, awkward, or “unscientific” based on our current understanding. Nonetheless, the concepts of health and disease they developed, despite the limited biological research, were remarkably insightful and, as well demonstrated by the more than 200 chapters in this textbook, have almost all now been fully validated. In fact, a number of their dire predictions of increased incidence of chronic disease if conventional medicine practices became dominant have now been conclusively demonstrated to have been correct. We urge the reader to focus on the evolution of the concepts and not be distracted by the antiquated terminology.

forerunners of these concepts already existed in the history of natural healing, both in America and in the Austro-Germanic European core. Lust came to this country from Germany in the 1890s as a disciple of Father Sebastian Kneipp, a Dominican priest, and as an emissary dispatched by Father Kneipp to bring hydrotherapy to America. Lust purchased the term naturopathy from Scheel in 1902 to describe the eclectic compilation of doctrines of natural healing that he envisioned to be the future of natural medicine. In January 1902, Lust, who had been publishing the Kneipp Water Cure Monthly and its Germanlanguage counterpart in New York since 1896, changed the name of the journal to The Naturopath and Herald of Health and evoked the dawn of a new health care era with the following editorial:

INTRODUCTION Naturopathy, as a generally used term, emerged in America from the writings and promotion of Benedict Lust. Naturopathy, or “nature cure,” is both a way of life and a concept of healing that employs various natural means of treating human infirmities and disease states. The earliest mechanisms of healing associated with the term, as used by Lust, involved a combination of hygienics and hydropathy (hydrotherapy). The term itself was coined in 1895 by Dr. John Scheel of New York City to describe his method of health care. However, earlier * Previous edition contributor

Naturopathy is a hybrid word. It is purposely so. No single tongue could distinguish a system whose origin, scope and purpose is universal—broad as the world, deep as love, high as heaven. Naturopathy was not born of a sudden or a happen-so. Its progenitors have for eons been projecting thoughts and ideas and ideals whose culminations are crystallized in the new Therapy. Connaro, doling out his few fixed ounces of food and drink each day in his determined exemplification of Dietotherapy; Priessnitz, agonizing, despised and dejected through the long years of Hydropathy’s travail; the Woerishofen priest, laboring lovingly in his little parish home for the thousands who journeyed Germany over for the Kneipp cure; Kuhne, living vicariously and dying a martyr for the sake of Serotherapy; A.T. Still, studying and struggling and enduring for his faith in Osteopathy; Bernarr Macfadden, fired by the will to make Physical Culture popular; Helen Willmans, threading the mazes of Mental Science, and finally emerging triumphant; Orrison Sweet Maraden, throbbing in sympathy with human faults and failures, and longing to realize Success to all mankind—these and hosts of

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others have brought into being single systems whose focal features are perpetuated in Naturopathy. Jesus Christ—I say it reverently—knew the possibility of physical immortality. He believed in bodily beauty; He founded Mental Healing; He perfected Spirit-power. And Naturopathy will include ultimately the supreme forces that made the Man of Galilee omnipotent.The scope of Naturopathy is from the first kiss of the new-found lovers to the burying of the centenarian whose birth was the symbol of their perfected one-ness. It includes ideally every life-phase of the id, the embryo, the foetus, the birth, the babe, the child, the youth, the man, the lover, the husband, the father, the patriarch, the soul. We believe in strong, pure, beautiful bodies thrilling perpetually with the glorious power of radiating health. We want every man, woman and child in this great land to know and embody and feel the truths of right living that mean conscious mastery. We plead for the renouncing of poisons from the coffee, white flour, glucose, lard, and like venom of the American table to patent medicines, tobacco, liquor and the other inevitable recourse of perverted appetite. We long for the time when an eight-hour day may enable every worker to stop existing long enough to live; when the spirit of universal brotherhood shall animate business and society and the church; when every American may have a little cottage of his own, and a bit of ground where he may combine Aerotherapy, Heliotherapy, Geotherapy, Aristophagy and nature’s other forces with home and peace and happiness and things forbidden to flat-dwellers; when people may stop doing and thinking and being for others and be for themselves; when true love and divine marriage and pre-natal culture and controlled parenthood may fill this world with germ-gods instead of humanized animals.In a word, Naturopathy stands for the reconciling, harmonizing and unifying of nature, humanity and God. Fundamentally therapeutic because men need healing; elementally educational because men need teaching; ultimately inspirational because men need empowering, it encompasses the realm of human progress and destiny. Perhaps a word of appreciation is due Mr. John H. Scheel, who first used the term “Naturopathic” in connection with his Sanitarium “Badekur,” and who has courteously allowed us to share the name. It was chosen out of some 150 submitted, as most comprehensive and enduring. All our present plans are looking forward some five or ten or fifty years when Naturopathy shall be the greatest system in the world. Actually the present development of Naturopathy is pitifully inadequate, and we shall from time to time present plans and ask suggestions for the surpassing achievement of our world-wide purpose. Dietetics, Physical Culture and Hydropathy are the measures upon which Naturopathy is to build; mental culture is the means, and soul-selfhood is the motive. If the infinite immensity of plan, plea and purpose of this particular magazine and movement were told you, you would simply smile in your condescendingly superior way and straightway forget. Not having learned as yet what a brain and imagination and a will can do, you consider Naturopathy an ordinarily innocuous affair, with a lukewarm purpose back of it, and an ebbing future ahead of it. Such is the character of the average wishy-washy health movement and tumultuous wave of reform. Your incredulous smile would not discomfit us—we do not importune your belief, or your help, or your money. Wherein we differ from the orthodox self-labeled reformer, who cries for sympathy and cringes for shekels. We need money most persistently—a million dollars could be used to advantage in a single branch of the work already definitely planned and awaiting materialization; and we need co-operation

in a hundred different ways. But these are not the things we expect or deem best. Criticism, fair, full and unsparing is the one thing of value you can give this paper. Let me explain. Change is the keynote of this January issue—in form, title, make-up. If it please you, your subscription and a word to your still-benighted friends is ample appreciation. But if you don’t like it, say so. Tell us wherein the paper is inefficient or redundant or ill-advised, how it will more nearly fit into your personal needs, what we can do to make it the broadest, deepest, truest, most inspiring of the mighty host of printed powers. The most salient letter of less than 300 words will be printed in full, and we shall ask to present the writer with a subscription-receipt for life. By to-morrow you will probably have forgotten this request; by the day after you will have dropped back into your old ways of criminal eating and foolish drinking and sagged standing and congested sitting and narrow thinking and deadly fearing—until the next progress paper of New Thought or Mental Science or Dietetics or Physical Culture prods you into momentary activity. Between now and December we shall tell you just how to preserve the right attitude, physical and mental, without a single external aid; and how, every moment of every day, to tingle and pulsate and leap with the boundless ecstasy of manhood consciously nearing perfection. 

A BRIEF HISTORY OF EARLY AMERICAN MEDICINE WITH AN EMPHASIS ON NATURAL HEALING To understand the evolutionary history of naturopathic medicine in this country, it is necessary to view the internal development of the profession against the historical, social, and cultural backdrop of American social history.

Medicine in America: 1800–1875 In the America of 1800, although a professional medical class existed, medicine was primarily domestically oriented. An individual who fell ill was commonly nursed by a friend or family member who relied upon William Buchan’s Domestic Medicine (1769), John Wesley’s Primitive Physic (1747), or John Gunn’s Domestic Medicine (1830).1

Professional Medicine Professional medicine transferred from England and Scotland to America in prerevolutionary days. However, 18th- and early-19th-century America considered the concept of creating a small, elite, learned profession to run counter to the political and institutional concepts of early American democracy.1 The first medical school in the American colonies opened in 1765 at what was then the College of Philadelphia (later the University of Pennsylvania), and the school was dominated by revolutionary leader and physician Benjamin Rush, a signatory to the Declaration of Independence. The proliferation of medical schools to train the new professional medical class began seriously after the war of 1812. Between 1810 and 1820, new schools were established in Baltimore, Lexington, Cincinnati, and even in rural communities in Vermont and Western New York. Between 1820 and 1850, substantial numbers of schools were established in the western rural states. By 1850, there were 42 medical schools recognized in the United States, although there were only 3 in all of France. Generally, these schools were started by a group of five to seven local physicians approaching a local college with the idea of establishing a medical school in conjunction with the college’s educational facilities. The schools were largely apprenticeship based, and the professors received their remuneration directly from fees paid by the students.

CHAPTER 3 

The History of Naturopathic Medicine: Origins and Overview

The requirements for a doctor of medicine (MD) degree in late18th- and early-19th-century America were roughly as follows: • Knowledge of Latin and natural and experimental philosophy • Three years of serving an apprenticeship under practicing physicians • Attending two terms of lectures and passing of attendant examinations • A thesis Additionally, graduating students had to be at least 21 years of age.1 The rise of any professional class is gradual and marked by difficulties, and varying concepts existed as to the demarcation of a “professional” physician. Contrasts included graduates of medical school versus nongraduates, medical society members versus nonmembers, and licensed physicians versus unlicensed “doctors.” Licensing statutes came into existence between 1830 and 1850 but were soon repealed because they were considered “undemocratic” during the apex of Jacksonian democracy. 1 

Thomsonianism In 1822 the rise in popularity of Samuel Thomson and his publication of New Guide to Health helped frustrate the creation of a professional medical class. Thomson’s work was a compilation of his personal view of medical theory and American Indian herbal and medical botanical lore. Thomson espoused the belief that disease had one general cause—“cold” influences on the human body—and that disease therefore had one general remedy: “heat.” Unlike the followers of Benjamin Rush and the American “heroic” medical tradition who advocated blood-letting, leeching, and the substantial use of mineral-based purgatives such as antimony and mercury, Thomson believed that minerals were sources of “cold” because they came from the ground and that vegetation, which grew toward the sun, represented “heat.” 1 As noted in Griggs’s Green Pharmacy (the best history of herbal medicine to date), Thomson’s theory developed as follows2: Instead, he elaborated a theory of his own, of the utmost simplicity: “All diseases … are brought about by a decrease or derangement of the vital fluids by taking cold or the loss of animal warmth … the name of the complaint depends upon what part of the body has become so weak as to be affected. If the lungs, it is consumption, or the pleura, pleurisy; if the limbs, it is rheumatism, or the bowels, colic or cholera morbus … all these different diseases may be removed by a restoration of the vital energy, and removing the obstructions which the disease has generated …” Thus the great object of his treatment was always to raise and restore the body’s vital heat: “All … that medicine can do in the expulsion of disorder, is to kindle up the decaying spark, and restore its energy till it glows in all its wonted vigor.” Thomson’s view was that individuals could be self-treating if they had a sincere “guide to health” philosophy and a copy of his book, New Guide to Health. The right to sell “family franchises” for the use of the Thomsonian method of healing was the basis of a profound lay movement between 1822 and Thomson’s death in 1843. Thomson adamantly believed that no professional medical class should exist and that democratic medicine was best practiced by laypersons within a Thomsonian “family” unit. By 1839, Thomson claimed to have sold some 100,000 of these family franchises called “friendly botanic societies.” Although he professed to have solely the interests of the individual at heart, his system was sold at a profit under the protection of a patent he obtained in 1813. 

The Eclectic School of Medicine Some of the “botanics” (professional Thomsonian doctors) wanted to separate themselves from the lay movement by creating requirements

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and standards for the practice of Thomsonian medicine. Thomson, however, was adamantly against a medical school founded on his views. Thus it was not until the decade after Thomson’s death that independent Thomsonians founded a medical college (in Cincinnati) and began to dominate the Thomsonian movement. These Thomsonian botanics were later absorbed into the medical sectarian movement known as the “eclectic school,” which originated with the New Yorker Wooster Beach. Beach was another of medical history’s fascinating characters. From a well-established New England family, he started his medical studies at an early age, apprenticing under an old German herbal doctor, Jacob Tidd. After Tidd died, Beach enrolled in the Barclay Street Medical University in New York. Griggs2 described the following: Beach’s burning ambition was to reform medical practice generally—not to alienate the entire profession by savage attacks from without—and he was convinced that he would be in a stronger position to do so if he were himself a diplomatized doctor. The faculty occasionally listened to criticism from within their own number: against onslaughts of “illiterate quacks” like Samuel Thomson, they simply closed ranks in complacent hostility. After opening his own practice in New York, Beach set out to win over fellow members of the New York Medical Society (into which he had been warmly introduced by the screening committee) to his point of view that heroic medicine was inherently dangerous to mankind and should be reduced to the gentler theories of herbal medicine. He was summarily ostracized from the medical society. To Beach, this was a bitter blow, but he soon founded his own school in New York, calling the clinic and educational facility the “United States Infirmary.” However, because of continued pressure from the medical society, he was unable to obtain charter authority to issue legitimate diplomas. He then located a financially ailing but legally chartered school, Worthington College, in Ohio. He opened a full-scale medical college; out of its classrooms, he launched what became known as the Eclectic School of Medical Theory. Griggs related the following2: Beach had a new name for his practice: While explaining to a friend his notions of combining what was useful in the old practice with what was best in the new, the friend exclaimed, “You are an eclectic!” to which, according to legend, Beach replied, “You have given me the term which I have wanted: I am an eclectic!” Cincinnati subsequently became the focal point of the eclectic movement, and the E. M. Institute medical school remained until 1938 (the last eclectic school to exist in America).3 The concepts of this sect helped form some of the theoretical underpinnings of Lust’s naturopathy. Lust himself graduated from the Eclectic Medical College of the City of New York in the first decade of the 1900s. Despite his criticism of the early allopathic movement (although the followers of Rush were not yet known as allopaths, a term reputed to have been coined by Samuel Hahnemann) for their “heroic” tendencies, Thomson’s medical theories were “heroic” in their own fashion. Although he did not advocate blood-letting, heavy metal poisoning, and leeching, botanic purgatives—particularly Lobelia inflata (Indian tobacco)—were a substantial part of the therapy. 

The Hygienic School of Thought One other forerunner of American naturopathy, also originating as a lay movement, grew into existence at this time. This was the “hygienic” school, which had its genesis in the popular teachings of Sylvester Graham and William Alcott. Graham began preaching the doctrines of temperance and hygiene in 1830. In 1839 he published Lectures on the Science of Human Life,

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two hefty volumes that prescribed healthy dietary habits. He emphasized a moderate lifestyle, recommending an antiflesh diet and bran bread as an alternative to bolted or white bread. Alcott dominated the scene in Boston during this same period and, together with Graham, saw that the American hygienic movement—at least as a lay doctrine—was well established.4 

Homeopathy By 1840, the profession of homeopathy had also been transplanted to America from Germany. Homeopathy, the creation of an early German physician, Samuel Hahnemann (1755–1843), had three central doctrines: • The “law of similars” (that like cures like) • That the effect of a medication could be heightened by its administration in minute doses (the more diluted the dose, the greater the “dynamic” effect) • That nearly all diseases were the result of a suppressed itch, or “psora” The view was that a patient’s natural symptom-producing disease would be displaced after homeopathic medication by a similar, but much weaker, artificial disease that the body’s immune system could easily overcome. Originally, most homeopaths in this country were converted orthodox medical men, or “allopaths.” The high rate of conversion made this particular medical sect the archenemy of the rising orthodox medical profession. (For a more detailed discussion of homeopathy, see Chapter 39.) The first homeopathic medical school was founded in 1850 in Cleveland; the last purely homeopathic medical school, based in Philadelphia, survived into the early 1930s. 1 

The Rise and Fall of the Sects Although these two nonallopathic sects were popular, they never comprised more than one fifth of the professional medical class in America. Homeopathy at its highest point reached roughly 15% and the eclectic school roughly 5%. However, their very existence for many years kept the exclusive recognition desired by the orthodox profession from coming within its grasp. Homeopathy was distasteful to the more conventional medical men not only because it resulted in the conversion of a substantial number of their peers but also because homeopaths generally also made a better income. The rejection of the eclectic school was more fundamental: it had its roots in a lay movement that challenged the validity of a privileged professional medical class. The existence of three professional medical groups—the orthodox school, the homeopaths, and the eclectics—combined with the Jacksonian view of democracy that prevailed in mid-19th-century America, resulted in the repeal of virtually all medical licensing statutes existing before 1850. However, by the 1870s and 1880s, all three medical groups began to voice support for the restoration of medical licensing. Views differ as to what caused the homeopathic and eclectic schools to disappear from the medical scene in the 50 years after 1875. One view defined a sect as follows5: A sect consists of a number of physicians, together with their professional institutions, who utilize a distinctive set of medically invalid therapies which are rejected by other sects. By this definition, the orthodox or allopathic school was just as sectarian as the homeopathic and eclectic schools. Rothstein’s view was that these two 19th-century sects disappeared because, beginning in the 1870s, the orthodox school grasped the European idea of “scientific medicine.” Based on the research of such men as Pasteur and Koch and the “germ theory,” this approach supposedly proved to be the

medically proper view of valid therapy and gained public recognition because of its truth. Another view was that the convergence of the needs of the three sects for professional medical recognition (which began in the 1870s and continued into the early 1900s) and the “progressive era” led to a political alliance in which the majority orthodox school was ultimately dominant by sheer weight of numbers and internal political authority. Starr1 noted the following: Both the homeopaths and eclectics wanted to share in the legal privileges of the profession. Only afterward did they lose their popularity. When homeopathic and eclectic doctors were shunned and denounced by the regular profession, they thrived, but the more they gained an access to the privileges of regular physicians, the more their numbers declined. The turn of the century was both the point of acceptance and the moment of incipient disintegration. In any event, this development was an integral part of the drive toward professional authority and autonomy established during the progressive era (1900–1917). It was acceptable to the homeopaths and the eclectics because they controlled medical schools that continued to teach and maintain their own professional authority and autonomy. However, it was after these professional goals were attained that the lesser schools of medical thought went into rapid decline. 1 

The American Influence From 1850 to 1900, the medical counterculture continued to establish itself in America. From its lay roots in the teachings of the hygienic movement grew professional medical recognition, albeit a small minority and “irregular” view, that hygiene and hydropathy were the basis of sound medical thought (much like the Thomsonian transition to botanic and eclectic medicine).

Russell Trall The earliest physician who had a significant effect on the later growth of naturopathy as a philosophic movement was Russell Trall, MD. As noted in James Whorton’s Crusaders for Fitness,4 he “passed like a meteor through the American hydropathic and hygienic movement”: The exemplar of the physical educator-hydropath was Russell Thatcher Trall. Still another physician who had lost his faith in regular therapy, Trall opened the second water cure establishment in America, in New York City in 1844. Immediately he combined the full Preissnitzian armamentarium of baths with regulation of diet, air, exercise and sleep. He would eventually open and or direct any number of other hydropathic institutions around the country, as well as edit the Water-Cure Journal, the Hydropathic Review, and a temperance journal. He authored several books, including popular sex manuals which perpetuated Graham-like concepts into the 1890s, sold Graham crackers and physiology texts at his New York office, was a charter member (and officer) of the American Vegetarian Society, presided over a short-lived World Health Association, and so on. His crowning accomplishment was the Hygeian Home, a “model Health Institution [which] is beautifully situated on the Delaware River between Trenton and Philadelphia.” A drawing presents it as a palatial establishment with expansive grounds for walking and riding, facilities for rowing, sailing, and swimming, and even a grove for open-air “dancing gymnastics.” It was the grandest of water cures, and lived beyond the Civil War period, which saw the demise of most hydropathic hospitals. True, Trall had to struggle to keep his head above water during the 1860s, but by the 1870s he had a firm financial footing (being stabilized by tuition fees from the attached Hygeio-therapeutic College). With Trall’s death in 1877, however, the hydropathic phase of health reform passed.

CHAPTER 3 

The History of Naturopathic Medicine: Origins and Overview

As made evident later in this chapter, this plethora of activity was similar to that engaged in by Benedict Lust between 1896 and his death in 1945, when he worked to establish naturopathy. The Hygeian Home and later “Yungborn” establishments at Butler, New Jersey, and Tangerine, Florida, were similar to European nature cure sanitariums, such as the original Yungborn founded by Adolph Just and the spa/ sanitarium facilities of Preissnitz, Kneipp, and Just. Trall gave a famous address to the Smithsonian Institution in Washington, DC, in 1862, under the sponsorship of the Washington Lecture Association. “The true healing art: or hygienic vs drug medication,” a 2.5-hour lecture purported to have received rapt attention, was devoted to Trall’s belief in the hygienic system and in hydropathy as the true healing art. The address was reprinted by Fowler and Wells (New York, 1880) with an introduction written by Trall, before his death in 1877. Trall also founded the first school of natural healing arts in this country to have a 4-year curriculum and the authorization to confer the degree of MD. It was founded in 1852 as a “hydropathic and physiological school” and was chartered by the New York State Legislature in 1857 under the name “New York Hygio-Therapeutic College,” with the legislature’s authorization to confer the MD degree. In 1862 Trall went to Europe to attend the International Temperance Convention. He took a prominent part at this meeting of reformers, specifically related to the use of alcohol as a beverage and as a medicine. He eventually published more than 25 books on the subjects of physiology, hydropathy, hygiene, vegetarianism, and temperance, among many others. The most valuable and enduring of these was his Hydropathic Encyclopedia, a volume of nearly 1000 pages that covered the theory and practice of hydropathy and the philosophy and treatment of diseases advanced by older schools of medicine. At the time of his death, according to the December 1877 Phrenological Journal cover article featuring a lengthy obituary of Trall, this encyclopedia had sold more than 40,000 copies since its original publication in 1851. For more than 15 years, Trall was editor of the Water-Cure Journal (also published by Fowler and Wells). During this period, the journal went through several name changes, including the Hygienic Teacher and The Herald of Health. When Lust originally opened the American School of Naturopathy, an English-language version of Kneipp’s Water-cure (or Meine Wasser-kurr in German) being unavailable, he used only the works and writings of Trall as his texts. 

Martin Luther Holbrook By 1871, Trall moved from New York to the Hygeian Home on the Delaware River. His water-cure establishment in New York became the New Hygienic Institute. One of its coproprietors was Martin Luther Holbrook, who later replaced Trall as the editor of The Herald of Health. Professor Whorton noted the following4: But Holbrook’s greatest service to the cause was as an editor. In 1866 he replaced Trall at the head of The Herald of Health, which had descended from the Water-Cure Journal and Herald of Reforms (1845–1861) by the way of the Hygienic Teacher and Water-Cure Journal (1862). Under Holbrook’s direction the periodical would pass through two more name changes (Journal of Hygiene Herald of Health, 1893–1897, and Omega, 1898–1900) before merging with Physical Culture. Trall and Holbrook both advanced the idea that physicians should teach the maintenance of health rather than simply providing a last resort in times of health crisis. Besides providing a strong editorial voice espousing vegetarianism, the evils of tobacco and drugs, and the value of bathing and exercise, dietetics and nutrition, along with

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personal hygiene, were strongly advanced by Holbrook and others of the hygienic movement during this era. Whorton described the idea as follows4: The orthodox hygienists of the progressive years were equally enthused by the recent progress of nutrition, of course, and exploited it for their own ends, but their utilization of science hardly stopped with dietetics. Medical bacteriology was another area of remarkable discovery, bacteriologists having provided, in the short space of the last quarter of the 19th century, an understanding, at long last, of the nature of infection. This new science’s implications for hygienic ideology were profound—when Holbrook locked horns with female fashion, for example, he did not attack the bulky, ground-length skirts still in style with the crude Grahamite objection that the skirt was too heavy. Rather he forced a gasp from his readers with an account of watching a smartly dressed lady unwittingly drag her skirt “over some virulent, revolting looking sputum, which some unfortunate consumptive had expectorated.” Holbrook expanded on the work of Graham, Alcott, and Trall and, working with an awareness of the European concepts developed by Preissnitz and Kneipp, laid further groundwork for the concepts later advanced by Lust, Lindlahr, and others4: For disease to result, the latter had to provide a suitable culture medium, had to be susceptible. As yet, most physicians were still so excited at having discovered the causative agents of infection that they were paying less than adequate notice to the host. Radical hygienists, however, were bent just as far in the other direction. They were inclined to see bacteria as merely impotent organisms that throve only in individuals whose hygienic carelessness had made their body compost heaps. Tuberculosis is contagious, Holbrook acknowledged, but “the degree of vital resistance is the real element of protection. When there is no preparation of the soil by heredity, predisposition or lowered health standard, the individual is amply guarded against the attack.” A theory favored by many others was that germs were the effect of disease rather than its cause; tissues corrupted by poor hygiene offered microbes, all harmless, an environment in which they could thrive. In addition to introducing the works of Kneipp and his teachings to the American hygienic healthcare movement, Holbrook was a leader of the fight against vivisection and vaccination4: Vivisection and vaccination were but two of the practices of medicine criticized in the late 19th century. Therapy also continued to be an object of protest. Although the heroism of standard treatment had declined markedly since mid-century, a prescription was still the reward of any visit to the doctor, and drugless alternatives to healing were appearing in protest. Holbrook published frequent favorable commentaries on the revised water cure system of Germany’s Kneipp. A combination of baths, herbal teas, and hardening exercises, the system had some vogue in the 1890’s before flowering into naturopathy. Holbrook’s journal also gave positive notices to osteopathy and “chiropathy” [chiropractic], commending them for not going to the “drugstore or ransack[ing] creation for remedies nor load[ing] the blood with poison.” But though bathing and musculoskeletal manipulation were natural and nonpoisonous, Holbrook preferred to give the body complete responsibility for healing itself. Rest and proper diet were the medicines of this doctor who billed himself as a “hygienic physician” and censured ordinary physicians for being engrossed with disease rather than health. 

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Philosophy of Natural Medicine

The Beginnings of “Scientific Medicine”

Medical Education in Transition

While the hygienic movement was making its effect, the orthodox medical profession, in alliance with the homeopaths and eclectics, was making significant advances. The orthodox profession, through the political efforts of the American Medical Association (AMA), first tried to remove sectarian and irregular practitioners by segregating them from the medical profession altogether. It did so by formulating and publishing its first national medical code of ethics in 1847. (In 1846 the orthodox profession formed the AMA to represent its professional views.) The code condemned proprietary patents (even carrying over into a physician’s development of surgical or other medical implements, which led to its greatest criticism); encouraged the adoption of uniform rules for payment in geographic areas; condemned the practice of contract work; prohibited advertising and fee-sharing even among specialists and general practitioners; eliminated blacks and women; and, most significantly, prohibited any consultation or contact with irregulars or sectarian practitioners. The code stated the following6:

Based on the rising example of scientific medicine and its necessary connection to research, the educational laboratory, and a more thorough scientific education as a preamble to medical practice, Harvard University (under the presidency of Charles Elliott) created a 4-year medical educational program in 1871. The primal modern medical educational curriculum was devised and set in motion more than 20 years later at Johns Hopkins University under the leadership of William Osler and William Welch, using the resources from the original endowment of the hospital and university from the estate of Johns Hopkins.1 Other schools followed suit. By the time the AMA set up its Council on Medical Education in 1904, it was made up of five members from the faculties of schools modeled on the Johns Hopkins prototype. This committee set out to visit and rate each of the 160 medical schools then in operation in the country. The ratings used were class A (acceptable), class B (doubtful), and class C (unacceptable). Eighty-two schools received a class A rating, led by Harvard, Rush (Chicago), Western Reserve, the University of California, and notably, Johns Hopkins. Forty-six schools received a class B rating, and 32 received a class C rating. The class C schools were mostly in rural areas, and many of them were proprietary in nature. 

No one can be considered as a regular practitioner, or a fit associate in consultation, whose practice is based on an exclusive dogma, to the rejection of the accumulated experience of the profession, and of the aids actually furnished by anatomy, physiology, pathology, and organic chemistry. In the late 1870s and into the 1880s the major sects—the orthodox or allopathic school, the homeopaths, and the eclectics—began to find more reason to cooperate to obtain common professional goals. These included the enactment of new licensing laws and the creation of a “respectable” medical educational system. Also at this time, the concept of “scientific medicine” was brought to America. (Although Starr differed from Rothstein regarding the causes of the decline of the homeopathic and eclectic sectarian schools, he noted that Rothstein clearly documented the 19th-century transition of medicine into a recognized professional class composed of both the minority sects and the orthodox school.) This transition from conflict between the major sects resulted in the erosion of the implementation of the code of ethics; the cooperation among the sects to revive medical licensing standards; the admission of sectarian physicians to regular medical societies; and ultimately, a structural reorganization of the AMA, which occurred between 1875 and 1903.15 Once the cooperation among the three medical views began, the medical class dominated by the regular school came fully into power. The homeopathic and eclectic schools of thought met their demise finally because of two significant events: (1) the rapid creation of new medical educational standards between 1900 and 1910, culminating in the publication of the famous “Flexner Report” (1910), and (2) the effective infusion of millions of dollars into selected allopathic medical schools by the newly created capitalistic philanthropic foundations, principally the Carnegie and Rockefeller Foundations.

The Foundations The effect of the monies from the Carnegie and Rockefeller Foundations was clearly documented7 and described in detail in Brown’s Rockefeller Medicine Men.8 The effect of the monies from these foundations, contributed to medical schools that met the AMA’s views on medical education and philosophy, cannot be underestimated. This process has been well documented.1,7,9,10 As discussed by Burrows,10 these educational reforms allowed the AMA to forge a new alliance with state legislators and push quickly for medical licensing designed to reward the educational and medical expertise of the newly orthodox “scientific medicine” and to the exclusion of all others. 

Flexner Report Subsequent to the AMA ratings, the Council on Medical Education applied to the Carnegie Foundation to commission an independent report to verify its work. Abraham Flexner, a young, energetic, and noted educator, was chosen for this task by the Carnegie Foundation and accompanied by the secretary (Nathan Colwell, MD) of the Council on Medical Education, who participated in all of the committee site visits. Flexner visited each of the 162 operating U.S. medical schools. The widely publicized Flexner Report put the nails in the coffins of all schools with class C ratings and many with class B ratings. Significantly, the educational programs of all but one eclectic school (in Cincinnati) and one homeopathic school (in Philadelphia) were eliminated by 1918. The eclectic medical schools, in particular, were severely affected by the report. Griggs explained this effect as follows2: Of the eight Eclectic schools, the Report declared that none had “anything remotely resembling the laboratory equipment which is claimed in their catalogs.” Three of them were under-equipped; the rest “are without exception filthy and almost bare. They have at best grimy little laboratories … a few microscopes, some bottles containing discolored and unlabeled pathological material, in an incubator out of commission, and a horrid dissecting room.” The Report found them more culpable than a regular school for these inadequacies: “… the Eclectics are drug-mad; yet, with the exception of the Cincinnati and New York schools, they are not equipped to teach the drugs or drug therapy which constitutes their sole reason for existence.” The other regular schools that conducted homeopathic or eclectic programs had by that time phased them out in the name of “scientific medicine” (see also Haller3). 

Pharmaceutical Industry During this same time, the AMA, through several of its efforts, began a significant alliance with the organized pharmaceutical industry of the United States, shaping it in a manner acceptable to the allopathic profession.1,9,11 

CHAPTER 3 

The History of Naturopathic Medicine: Origins and Overview

The New “Sects” The period from 1890 to 1905 saw the rise of three new medical sects and several other smaller “irregular” schools that replaced those soon to pass from the scene. In Missouri, Andrew Taylor Still, originally trained as an orthodox practitioner, founded the school of medical thought known as “osteopathy” and in 1892 opened the American School of Osteopathy in Kirksville, Missouri. In 1895 Daniel David Palmer, originally a magnetic healer from Davenport, Iowa, performed the first spinal manipulation, which gave rise to the school he termed “chiropractic.” He formally published his findings in 1910, after having founded a chiropractic school in Davenport, Iowa. In 1902 Lust founded the American School of Naturopathy in New York. Although some of the following discussions are devoted to the schools of healing called osteopathy and chiropractic, only that portion of their histories related to the history of naturopathy is mentioned.12 (A full study of osteopathic medicine in America may be found in The D.O.’s by Gevitz,13 and a reasonable sketch of chiropractic medicine may be found in Kapling’s chapter in Alternative Medicine.12) As noted by Starr,1 these new sects, including Christian Science, formulated by Mary Baker Eddy,14 either rose or fell on their own without ever completely allying with orthodox medicine. Starr theorized that these sects arose late enough that the orthodox profession and its political action arm, the AMA, had no need to ally with them and would rather battle with them publicly. This made these sectarian views separate and distinct from the homeopathic and eclectic schools. 

THE FOUNDING OF NATUROPATHIC MEDICINE Benedict Lust Lust came to the United States in 1892 at the age of 23. He suffered from a debilitating condition in his late teens while growing up in Michelbach, Baden, Germany, and was sent by his father to undergo the Kneipp cure at Woerishofen. He stayed there from mid-1890 to early 1892; not only was he “cured” of his condition, but he also became a protégé of Kneipp. Dispatched by Kneipp to bring the principles of the Kneipp water cure to America, he emigrated to New York City. By making contact in New York with other German Americans who were also becoming aware of the Kneipp principles, Lust participated in the founding of the first “Kneipp Society,” which was organized in Jersey City, New Jersey, in October 1896. Lust also attended the first organizational meeting (in mid-October 1896) of the Kneipp Society of Brooklyn. Subsequently, through Lust’s organization and contacts, Kneipp Societies were founded in Boston; Chicago; Cleveland; Denver; Cincinnati; Philadelphia; Columbus; Buffalo and Rochester, New York; New Haven, Connecticut; San Francisco; New Mexico; and Mineola on Long Island, New York. The members of these organizations were provided with copies of the Kneipp Blatter and a companion English publication Lust began to put out called The Kneipp Water Cure Monthly. The first “sanatorium” using Kneipp’s principles was organized in this country shortly before Lust’s arrival. Charles Lauterwasser, an earlier student of Kneipp’s who called himself a hydrothic physician and natural scientist, opened the Kneipp and Nature Cure Sanatorium in Newark, New Jersey, in 1891. In 1895 the Brooklyn Light and Water-Cure Institute was established in Brooklyn, New York, by L. Staden and his wife Carola, both graduates of Lindlahr’s Hygienic College in Dresden, Germany. According to their advertising, they specialized in natural healing, Kneipp water treatment, and Kuhne’s and Preissnitz’s principles (including diet cure, electric light baths [both white and blue], electric vibration massage, Swedish massage and movements, and Thure Brandt massage).

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In 1895 Lust opened the Kneipp Water-Cure Institute in New York City, listing himself as the owner and Dr. William Steffens as the residing physician. At the same address (on 59th Street) in October of that year, Lust opened the first “Kneipp store.” In the originating November 1896 edition of The Kneipp Water Cure Monthly and Kneipp Blatter, he advertised his store and sanitarium as personally authorized by Kneipp. In the first part of 1896, just before his organizing of various Kneipp Societies around the New York area, Lust returned to Woerishofen to study further with Kneipp. Kneipp died in Germany, at Woerishofen, in June 1897. With his passing, Lust was no longer bound strictly to the principles of the Kneipp water cure. He had begun to associate earlier with other German American physicians, principally Dr. Hugo R. Wendel (a German-trained Naturarzt), who began, in 1897, to practice in New York and New Jersey as a licensed osteopathic physician. In 1896 Lust entered the Universal Osteopathic College of New York, graduated in 1898, and became licensed as an osteopathic physician. In 1897 Lust became an American citizen. Once he was licensed to practice as a healthcare physician in his own right, Lust began the transition toward the concept of “naturopathy.” Between 1898 and 1902, when he adopted the term naturopath, Lust acquired a chiropractic education and changed the name of his Kneipp store to the Health Food Store (the original facility to use that name and concept in this country), specializing in providing organic foods and the materials necessary for drugless cures. He also began the New York School of Massage (listed as established in 1896) and the American School of Chiropractic, all within the same facility—Lust’s Kneipp Institute. Photographs of this facility taken between 1902 and 1907, when the facility moved to another location, show a five-story building listing “Benedict Lust—Naturopath, Publisher, Importer.” He returned to Germany in 1907 to visit with Dr. Baumgarten, Kneipp’s medical successor at the Woerishofen facility, which was then run, in cooperation with Baumgarten, by the Reverend Prior Reily, the former secretary to Kneipp and his lay successor at Woerishofen. As directed by Kneipp, Reily had completed, after Kneipp’s death, Kneipp’s masterwork Das grosse Kneipp—Buch. Lust maintained contact with the partnership of Reily and Baumgarten throughout the early part of the 20th century. In 1902 when he purchased and began using the term naturopathy and calling himself a “naturopath,” Lust, in addition to his New York School of Massage and American School of Chiropractic, his various publications, and his operation of the Health Food Store, began to operate the American School of Naturopathy, all at the same 59th Street New York address. By 1907 Lust’s enterprises had grown sufficiently large that he moved them to a 55-room building. It housed the Naturopathic Institute, Clinic, and Hospital; the American Schools of Naturopathy and Chiropractic; the now-entitled Original Health Food Store; Lust’s publishing enterprises; and the New York School of Massage. The operation remained in this four-story building, roughly twice the size of the original facility, from 1907 to 1915. From 1912 to 1914, Lust took a “sabbatical” from his operations to further his medical education. By this time, he had founded his large estate-like sanitarium in Butler, New Jersey, known as “Yungborn” after the German sanitarium operation of Adolph Just. In 1912 he attended the Homeopathic Medical College in New York, which, in 1913, granted him a degree in homeopathic medicine, and in 1914, he received his degree in eclectic medicine. In early 1914 Lust traveled to Florida and obtained an MD’s license on the basis of his graduation from the Homeopathic Medical College and the Eclectic Medical College of New York City.

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Philosophy of Natural Medicine

He founded another “Yungborn” sanitarium facility in Tangerine, Florida, and for the rest of his life, while continuing his publications, he engaged in active public lecturing. He also continued to maintain a practice in New York City and operated the sanitariums in Florida and New Jersey. His schools were operated primarily by Hugo R. Wendel. From 1902, when he began to use the term naturopathy, until 1918, Lust replaced the Kneipp Societies with the Naturopathic Society of America. Then, in December 1919, the Naturopathic Society of America was formally dissolved because of its insolvency, and Lust founded the American Naturopathic Association (ANA). Thereafter, 18 states incorporated the association. In 1918, as part of his effort to replace the Naturopathic Society of America (an operation into which he invested a great deal of his funds and resources in an attempt to organize a naturopathic profession) and replace it with the ANA, Lust published the first Universal Naturopathic Directory and Buyer’s Guide (a “yearbook of drugless therapy”). Although a completely new version was never actually published, despite Lust’s announced intention to make this volume an annual publication, annual supplements were published in either The Naturopath and Herald of Health or its companion publication Nature’s Path (which commenced publication in 1925). The Naturopath and Herald of Health, sometimes printed with the two phrases reversed, was published from 1902 to 1927 and from 1934 until after Lust’s death in 1945. This volume documented the merging of the German and American influences that guided Lust in his development of the practice of naturopathy. The voluminous tome, which ran to 1416 pages, was dedicated to: The memory of all those noble pioneers and discoverers who have died in the faith of Naturopathy, and to their courageous successors in the art of drugless healing, all of whom have suffered persecution for saving human lives that medical autocracy could not save, this work is respectfully dedicated by its editor Benedict Lust, N.D., M.D., “The Yungborn,” Butler, New Jersey, U.S.A., April 1, 1918. Lust’s introduction is reprinted here in its entirety to show the purpose of the directory and the status of the profession in the early 1900s: 

Introduction To the Naturopathic Profession, the Professors of Natural Healing in all its branches, the Professors of Scientific Diet, Hydrotherapy, Heliotherapy, Electrotherapy, Neuropathy, Osteopathy, Chiropractic, Naprapathy, Magnetopathy, Phytotherapy, Exercise, Swedish Movements, Curative Gymnastics, Physical and Mental Culture, Balneopathy, and all forms of Drugless Healing, the Faculties of all Drugless Colleges, Institutions, Schools, and all Professors of Hygiene and Sanitation; Manufacturers of Naturopathic Supplies; Publishers of Health Literature, and Natural Healing Societies, GREETINGS: I have the honor to present to your consideration and goodwill, this Volume, No. 1, Year 1918–1919, of the Universal Naturopathic Directory, Year Book of Drugless Healing, and Buyers’ Guide. For twenty-two years past, the need of a directory for Drugless Therapy has been felt. The medical world is in a condition of intense evolution at the present time. It is evolving from the Drugging School of Therapy to the Drugless School. People by the million have lost confidence in the virtues of Allopathy and are turning with joyful confidence to the Professions of Natural Healing until it has been estimated that there are at least forty thousand practitioners of Naturopathic healing in the United States.The motto that IN UNITY THERE IS STRENGTH is the foundation of the present enterprise.

Hitherto, the drugless profession has lacked that prestige in the eyes of the public, which comes from the continuous existence of a big institution, duly organized and wielding the immense authority which is derived no less from organization and history than from the virtues of the principles that are held and practiced by such institutions. The public at large instantaneously respects an institution that is thoroughly organized and has its root earthed in history. The time has fully arrived when the drugless profession should no longer exist in the form of isolated units, not knowing one another and caring but little for such knowledge. Our profession has been, as it were, as sheep without a shepherd, but the various individuals that constitute this movement so pregnant with benefits to humanity, are now collected for the first time into a Directory and Year-Book of Drugless Healing, which alone will give immense weight and dignity to the standing of the individuals mentioned therein.Not only will the book add to the prestige of the practitioner in the eyes of his patients, but when the scattered members of our profession in every State desire to obtain legislative action on behalf of their profession and themselves, the appeal of such a work as our directory will, in the eyes of legislators, gain for them a much more respectful hearing than could otherwise be obtained. Now, for the first time, the drugless practitioner finds himself one of a vast army of professional men and women who are employing the most healthful forces of nature to rejuvenate and regenerate the world. But the book itself throws a powerful light upon every phase of drugless healing and annihilates time and distance in investigating WHO IS WHO in the realm of Drugless Therapy. A most sincere effort has been made to obtain the name and address of every adherent of the Rational School of Medicine who practices his profession within the United States, Canada and the British Isles. It is impossible at this stage of Naturopathic history, which is still largely in the making, to obtain the name and address of every such practitioner. There were some who, even when appealed to, refused to respond to our invitation, not understanding the object of our work. Many of even the most intelligent members have refused to advertise their professional cards in our pages. But we can only attribute these drawbacks to the fact that every new institution that has suddenly dawned upon human intelligence will find that a certain proportion of people who do not understand the nature of the enterprise because the brain cells that would appreciate the benefits that are sought to be conferred upon them, are undeveloped, but a goodly proportion of our Naturopaths have gladly responded to the invitation to advertise their specialty in our columns. These, of course, constitute the brightest and most successful of our practitioners and their examples in this respect should be followed by every practitioner whose card does not appear in this book.We take it for granted that every one of the forty thousand practitioners of Naturopathy is in favor of the enterprise represented by this Directory. This work is a tool of his trade and not to possess this book is a serious handicap in the race for success. Here will be found an Index of by far the larger number of Naturopaths in the country arranged in Alphabetic, Geographic and Naturopathic sections. Besides this, there is a classified Buyers’ Guide that gives immediate information regarding where you can find special supplies, or a certain apparatus, or a certain book or magazine, its name, and where it is published. The list of Institutions with the curriculum of each will be found exceedingly useful. Natural healing, that has drifted so long, and, by reason of a lack of organization, has been made for so many years the football of official medicine, to be kicked by any one who thought fit to do so, has now arrived at such a pitch of power that it has shaken the old system of bureaucratic medicine to its foundations. The

CHAPTER 3 

The History of Naturopathic Medicine: Origins and Overview

professors of the irrational theories of life, health and disease, that are looking for victims to be inoculated with dangerous drugs and animalized vaccines and serums, have begun to fear the growth of this young giant of medical healing that demands medical freedom, social justice and equal rights for the new healing system that exists alone for the betterment and uplifting of humanity. I want every Professor of Drugless Therapy to become my friend and co-worker in the great cause to which we are committed, and those whose names are not recorded in this book should send them to me without delay. It will be of far greater interest and value to themselves to have their professional card included amongst those who advertise with us than the few dollars that such advertisement costs. It will be noted that there are quite a number of Drugless Healers belonging to foreign countries (particularly those of the Western Hemisphere) represented in this Directory. The profession of medicine is not confined to any race, country, clime or religion. It is a universal profession and demands universal recognition. It will be a great honor to the Directory, as well as to the Naturopathic profession at large to have every Naturopathic practitioner, from the Arctic Circle to the furthest limits of Patagonia, represented in the pages of this immense and most helpful work. I expect that the Directory for the year 1920 will be larger and even more important than the present Directory and that it will contain the names of thousands of practitioners that are not included in the present work. The publication of this Directory will aid in abolishing whatever evils of sectarianism, narrow-mindedness and lack of loyalty to the cause to which we are devoted, that may exist. That it will promote a fraternal spirit among all exponents of natural healing, and create an increase of their prestige and power to resist the encroachments of official medicine on their constitutional rights of liberty and the pursuit of happiness, by favorably influencing Legislators, Law courts, City Councils and Boards of Health everywhere, is the sincere belief of the editor and publisher. Having introduced the volume, Lust leads off with his article entitled “The principles, aim, and program of the nature cure system.” Again, this relatively brief article is reproduced here in its entirety so that one can see the merging of influences: 

The Principles, Aim, and Program of the Nature Cure System Since the earliest ages, Medical Science has been of all sciences the most unscientific. Its professors, with few exceptions, have sought to cure disease by the magic of pills and potions and poisons that attacked the ailment with the idea of suppressing the symptoms instead of attacking the real cause of the ailment. Medical science has always believed in the superstition that the use of chemical substances which are harmful and destructive to human life will prove an efficient substitute for the violation of laws, and in this way encourages the belief that a man may go the limit in self indulgences that weaken and destroy his physical system, and then hope to be absolved from his physical ailments by swallowing a few pills, or submitting to an injection of a serum or vaccine, that are supposed to act as vicarious redeemers of the physical organism and counteract life-long practices that are poisonous and wholly destructive to the patient’s well-being. From the earliest ages to the present time, the priests of medicine have discovered that it is ten times easier to obtain ten dollars from a man by acting upon his superstition, than it is to extract one dollar from him, by appealing to reason and common sense. Having this key to a gold mine within their grasp, we find official medicine

indulging at all times in the most blatant, outrageous, freakish and unscientific methods of curing disease, because the methods were in harmony with the medical prestige of the physician. Away back in pre-historic times, disease was regarded as a demon to be exorcized from its victim, and the medicine man of his tribe belabored the body of his patient with a bag in which rattled bones and feathers, and no doubt in extreme cases the tremendous faith in this process of cure that was engendered in the mind of the patient really cured some ailments for which mental science and not the bag of bones and feathers should be given credit. Coming down to the middle ages, the Witches’ Broth—one ingredient of which was the blood of a child murderer drawn in the dark of the moon—was sworn to, by official medicine, as a remedy for every disease. In a later period, the “docteur a la mode,” between his taking pinches of snuff from a gold snuff box, would order the patient bled as a remedy for what he denominated spirits, vapors, megrims, or miasms. Following this pseudo-scientific diagnosis and method of cure, came the drugging phase in which symptoms of disease were unmercifully attacked by all kinds of drugs, alkalis, acids and poisons which were supposed, that by suffocating the symptoms of disease, by smothering their destructive energy, to thus enhance the vitality of the individual. All these cures have had their inception, their period of extensive application, and their certain desuetude. The contemporary fashion of healing disease is that of serums, inoculations and vaccines, which, instead of being an improvement on the fake medicines of former ages are of no value in the cure of disease, but on the contrary introduce lesions into the human body of the most distressing and deadly import. The policy of expediency is at the basis of medical drug healing. It is along the lines of self-indulgence, indifference, ignorance and lack of self-control that drug medicine lives, moves and has its being. The sleeping swineries of mankind are wholly exploited by a system of medical treatment, founded on poisonous and revolting products, whose chemical composition and whose mode of attacking disease, are equally unknown to their originators, and this is called “Scientific medicine.” Like the alchemist of old who circulated the false belief that he could transmute the baser metals into gold, in like manner the vivisector claims that he can coin the agony of animals into cures for human disease. He insists on cursing animals that he may bless mankind with such curses. To understand how revolting these products are, let us just refer to the vaccine matter which is supposed to be an efficient preventive of smallpox. Who would be fool enough to swallow the putrid pus and corruption scraped from the foulest sores of smallpox that has been implanted in the body of a calf? Even if any one would be fool enough to drink so atrocious a substance, its danger might be neutralized by the digestive juices of the intestinal tract. But it is a far greater danger to the organism when inoculated into the blood and tissues direct, where no digestive substances can possibly neutralize its poison.The natural system for curing disease is based on a return to nature in regulating the diet, breathing, exercising, bathing and the employment of various forces to eliminate the poisonous products in the system, and so raise the vitality of the patient to a proper standard of health. Official medicine has in all ages simply attacked the symptoms of disease without paying any attention to the causes thereof, but natural healing is concerned far more with removing the causes of disease, than merely curing its symptoms. This is the glory of this new school of medicine that it cures by removing the causes of the ailment, and is the only rational method of practicing medicine.

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Philosophy of Natural Medicine

It begins its cures by avoiding the uses of drugs and hence is styled the system of drugless healing. It came first into vogue in Germany and its most famous exponents in that country were Priessnitz, Schroth, Kuhne, Kneipp, Rickli, Lahmann, Just, Ehret, Engelhardt, and others. In Sweden, Ling and others developed various systems of mechano-therapy and curative gymnastics. In America, Palmer invented Chiropractic; McCormick, Ophthalmology. Still originated Osteopathy; Weltmer, suggestive Therapeutics. Lindlahr combined the essentials of various natural methods, while Kellogg, Tilden, Schultz, Trall, Lust, Lahn, Arnold, Struch, Havard, Davis, Jackson, Walters, Deininger, Tyrell, Collins and others, have each of them spent a lifetime in studying and putting into practice the best ideas of drugless healing and have greatly enlarged and enriched the new school of medicine. 

Life Maltreated by Allopathy The prime object of natural healing is to give the principle of life the line of least resistance, that it may enable man to possess the most abundant health. 

What Is Life? The finite mind of man fails to comprehend the nature of this mysterious principle. The philosopher says “Life is the sum of the forces that resist death,” but that definition only increases its obscurity. Life is a most precious endowment of protoplasm, of the various combinations of oxygen, hydrogen, carbon and nitrogen, and other purely mineral substances in forming organic tissues. As Othello says, referring to Desdemona’s life, which he compares to the light of a candle— “If I quench thee thou flaming minister, I can thy former light restore Should I repent me; but once put out THY light, I know not whence is that Promethean heat That can thy light relume.” The spark of life flickers in the sockets of millions and is about to go out. What system of medicine will most surely restore that flickering spark to a steady, burning flame? Will [it be] the system that employs poisonous vaccines, serums and inoculations, whose medical value has to be supported by the most mendacious statements, and whose practitioners are far more intent on their emoluments and fame, than they are in the practice of humanity? The Allopathic system, which includes nine tenths of all medical practitioners, is known by its fruits, but it is an appalling fact that infant mortality, insanity, heart disease, arteriosclerosis, cancer, debility, impoverished constitutions, degeneracy, idiocy and inefficiency have enormously increased, particularly during the last twenty-five years, that is, during the regime of inoculations, serums and vaccines. Naturopathy, on the other hand, so far as it has been developed, and so far as official medicine will allow it to act, leaves no such trail of disease, disaster and death behind it. Natural healing is emancipation from medical superstition, ignorance and tyranny. It is the true Elixir of Life. The Allopaths have endeavored to cure sick humanity on the basis of the highly erroneous idea that man can change the laws of nature that govern our being, and cure the cause of disease by simply ignoring it. To cure disease by poisoning its symptoms is medical manslaughter. Dr. Schwenninger of Germany says: “We are suffering under the curse of the past mistakes of our profession. For thousands of years medical doctors have been educating the public into the false belief that poisonous drugs can give health. This belief has become in the public

mind such a deep-seated superstition, that those of us who know better and who would like to adopt more sensible, natural methods of cure, can do so only at the peril of losing practice and reputation. “The average medical man is at his best but a devoted bigot to this vain school-craft, which we call the Medical Art and which alone in this age of science has made no perceptible progress since the days of its earliest teachers. They call it recognized science! Recognized ignorance! The science of to-day is the ignorance of to-morrow. Every year some bold guess lights up as truth to which but the year before the schoolmen of science were as blind as moles.” And Dr. O.W. Holmes, Professor of Anatomy in Harvard University, states: “The disgrace of medicine has been that colossal system of self-deception, in obedience to which mines have been emptied of their cankering minerals, entrails of animals taxed for their impurities, the poison bags of reptiles drained of their venom, and all the inconceivable abominations thus obtained thrust down the throats of human beings, suffering from some fault of organization, nourishment, or vital stimulation.” And these misguided drug doctors are not only not ashamed of their work, but they have induced subservient legislators to pass laws that perpetuate the age-long scandal of allopathic importance, and the degenerative influence of the poisons, and to actually make it a crime on the part of nature doctors to cure a man of his ailment. The brazen effrontery of these medical despots has no limits. They boast of making the State legislators their catspaw in arresting, fining and imprisoning the professors of natural healing for saving human life. Legislators have no right to sit in judgment over the claims of rival schools of healing. They see tens of thousands of sick people go down to their graves by being denied the cures that the employers of nature’s forces alone can give them. It is their business to provide for the various schools of medicine a fair field and no favor. A citizen has an inalienable right to liberty in the pursuit of happiness. Yet the real saviors of mankind are persecuted by the medical oligarchy which is responsible for compulsory vaccination, compulsory medical inspection of public school children, and the demands for State and Federal departments of health, all for the ostensible good of the people, but in reality for the gain of the Medical Trust. 

The Naturopaths The Naturopaths are desirous of freedom for all schools of medicine. They are responsible practitioners who are willing to be examined by an impartial council, appointed by and acting for the State, who will testify to the life and character of every drugless physician before he is entitled to practice medicine. Not one invidious discrimination should be made between the different schools of medicine. The state should see to it that each school should have a full opportunity to do its best for the up-lifting of its citizens. 

The Program of Naturopathic Cure 1. ELIMINATION OF EVIL HABITS, or the weeds of life, such as overeating, alcoholic drinks, drugs, the use of tea, coffee and cocoa that contain poisons, meat eating, improper hours of living, waste of vital forces, lowered vitality, sexual and social aberrations, worry, etc. 2. CORRECTIVE HABITS. Correct breathing, correct exercise, right mental attitude. Moderation in the pursuit of health and wealth. 3. NEW PRINCIPLES OF LIVING. Proper fasting, selection of food, hydropathy, light and air baths, mud baths, osteopathy, chiropractic and other forms of mechano-therapy, mineral salts obtained in organic form, electropathy, heliopathy, steam or Turkish baths, sitz baths, etc.

CHAPTER 3 

The History of Naturopathic Medicine: Origins and Overview

Natural healing is the most desirable factor in the regeneration of the race. It is a return to nature in methods of living and treatment. It makes use of the elementary forces of nature, of chemical selection of foods that will constitute a correct medical dietary. The diet of civilized man is devitalized, is poor in essential organic salts. The fact that foods are cooked in so many ways and are salted, spiced, sweetened and otherwise made attractive to the palate, induces people to over-eat, and over eating does more harm than under feeding. High protein food and lazy habits are the cause of cancer, Bright’s disease, rheumatism and the poisons of auto-intoxication. There is really but one healing force in existence and that is Nature herself, which means the inherent restorative power of the organism to overcome disease. Now the question is, can this power be appropriated and guided more readily by extrinsic or intrinsic methods? That is to say, is it more amenable to combat disease by irritating drugs, vaccines and serums employed by superstitious moderns, or by the bland intrinsic congenial forces of Natural Therapeutics, that are employed by this new school of medicine, that is Naturopathy, which is the only orthodox school of medicine? Are not these natural forces much more orthodox than the artificial resources of the druggist? The practical application of these natural agencies, duly suited to the individual case, are true signs that the art of healing has been elaborated by the aid of absolutely harmless, congenial treatments, under whose ministration the death rate is but five per cent of persons treated as compared with fifty per cent under the present allopathic methods. 

The Germanic Influence The philosophic origins of naturopathy were Germanic. The most significant influences, except those of Russell Trall, the osteopathic concepts of A.T. Still (at this time, strictly the correction of spinal lesions by adjustment), and the chiropractic principles of D. D. Palmer, were originally Germanic. (This was well established in the January 1902 editorial in Water Cure Monthly.) The specific influences on which Lust drew for his work, in order of their chronologic contributions to the system of naturopathy, are the following: 1. Vincent Preissnitz (1799–1851) 2. Johann Schroth (1798–1856) 3. Father Sebastian Kneipp (1821–1897) 4. Arnold Rickli (1823–1926) 5. Louis Kuhne (c. 1823–1907) 6. Henry Lahman (no dates known) 7. F. E. Bilz (1823–1903) 8. Adolph Just (1859–1939). Also of note were Theodor Hahn and T. Meltzer, who, in the 1860s, were well known for their work in the movement called, in German, Naturatz or “naturism.” In photographs accompanying his article “The principles, aim and program of the nature cure system,” Lust described each of these thinkers as follows: 1. VINCENT PREISSNITZ, of Graefenberg, Silesia. Founder of Hydropathy. Born October 4, 1799. A pioneer Naturopath, prosecuted by the medical authorities of his day, and convicted of using witchcraft, because he cured his patients by the use of water, air, diet and exercise. He took his patients back to Nature—to the woods, the streams, the open fieldstreated them with Nature’s own forces and fed them on natural foods. His fame spread over the whole of Europe, and even to America. His cured patients were numbered by the thousands. The Preissnitz compress or bandage is in the medical literature. Preissnitz is no more, but his spirit lives in every true Naturopath.

2. JOHANN SCHROTH, a layperson, not described in Lust’s directory but often talked of in later works and prominently mentioned for his curative theories in Bilz’s master work, The Natural Method of Healing. Schroth smashed his right knee in an accident with a horse and it remained stiff in spite of repeated medical treatment. At last, a priest told Schroth that Preissnitz’s methods might help, and Schroth decided to give them a try. In order to avoid frequent changing of the packs that were directed by Preissnitz, he placed several packs on top of one another, wrapping the whole portion with a woolen cloth. He left this pack on the injured knee for several hours and produced a moist heat which he theorized to cause the poisonous toxins to dissolve and be swept away. These packs are still used as part of the “Schroth cure” and have reportedly become famous for their blood-cleansing effect. (From an article in the March 1937 Naturopath and Herald of Health by Dr. T.M. Schippel.) As noted by Bilz, the Schroth cure, called by Bilz “the regenerative treatment,” was developed for treatment of chronic diseases through the use of an extreme diet following total fasting by withdrawing of all food and drink and then the use of totally dry grain products and the eventual reintroduction of fluids. 3. FATHER SEBASTIAN KNEIPP, of course, is much described and the photos include one of Kneipp lecturing to the multitudes at Wandelhale at Woerishofen, attending Pope Leo XIII in 1893, noting this is the only consultation on health care matters that Kneipp ever consented to outside of Woerishofen, though many famous and aristocratic individuals desired his counsel, and a picture of Kneipp with the Archdukes Joseph and Francis Ferdinand of Austria walking barefoot in new-fallen snow for purposes of hardening the constitution. It was noted that the older Archduke was cured by Kneipp of Bright’s disease in 1892, and it noted that the Archduke Joseph, in appreciation of this cure, donated a public park in the town of Woerishofenat a cost of $150,000 florens. The Archduke Francis Ferdinand, the son of Archduke Joseph, was the individual whose murder precipitated World War I. There is a further picture of Kneipp surrounded consultation to numerous patients. 4. ARNOLD RICKLI, founder of the light and light and aircures (atmospheric cure). Dr. Rickli was one of the foremost exponents of natural living and healing. In 1848, he established at Veldes, Krain, Austria, the first institution of light and air cure or as it was called in Europe the “atmospheric cure.” In a limited way (rather very late) his ideas have been adopted by the medical profession in America for the cure of consumption. He was an ardent disciple of the vegetarian diet and exemplified the principles of natural living in his own life. The enclosed photo shows him at the age of 97, when he was still active and healthy. He has since passed on, but his work still lives as a testimonial of his untiring efforts. He was the founder and for over 50 years the President of the National Austrian Vegetarian Association. 5. LOUIS KUHNE wrote, in 1891, The New Science of Healing, the greatest work of basic principles in natural healing. In the tradition of Natural Healing and prevention, Kuhne has been described as one who “… advocated sun, steam baths, a vegetarian diet, and whole-wheat bread … in these relatively early days.” His renowned work constitutes the only true scientific philosophy for the application of all Drugless Methods. He was the first to give to the world the comprehensible idea of pathology and the first to proclaim the doctrine of the “unity of cure.” His book Facial Expression gives the means of diagnosing a patient’s pathological condition and determining the amount and location of the systemic encumbrance. He is the founder and first Master of Naturopathy.

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6. DR. H. LAHMAN. When the University of Leipzig expelled H. Lahman for his spreading medical sedition among the students, it added a staunch advocate to natural healing. Dr. Lahman finished his medical education in Switzerland and returned to Germany to refute in practice the false ideas of medical science. He later founded the largest Nature Cure institution in the world at Weisser Hirsch, near Dresden, Saxony. He was a strong believer in the “Light and Air” cure and constructed the first appliances for the administration of electric light treatment and baths. He was the author of several books on Diet, Nature Cure and Heliotherapy. As noted in Other Healers, Other Cures: “Heinrich Lahmann came along to stress no salt on foods and no water with meals …” His works on diet are authoritative and his “nutritive salts theory” forms the basis of rational dietetic treatment. This work has but recently come to light in America, and progressive dietitians are forsaking their old, wornout, high protein, chemical and caloric theories for the “organic salts theory.” Carque, Lindlahr, McCann, and other wide awake food scientists have adopted it as a basis for their work. Dr. Lahman was a medical nihilist. He denounced medicine as unscientific and entirely experimental in its practice and lived to prove the saneness of his ideas as evidenced by his thousands of cured patients. 7. PROFESSOR F.E. BILZ. That real physicians are born, not made, is well illustrated in the case of Dr. Bilz, who achieved his first success in healing as a lay practitioner. As a mark of gratitude, a wealthy patient presented him with land and a castle in which to found a Nature Cure anitarium.… The Bilz institution at Dresden-Rdebeul, Germany, became world renowned and was long considered the center of the Nature Cure movement. Professor Bilz is the author of the first Naturopathic encyclopedia, The Natural Method of Healing, which has been translated into a dozen languages, and in German alone has run into 150 editions. He has written many works on Nature Cure and Natural Life, among them being The Future State, in which he predicted the present World War, and advocated a federation of nations as the only logical solution of international problems. 8. ADOLPH JUST, famous author of Return to Nature and founder of original “Yungborn” in Germany. Both Adolph Just’s Return to Nature and Louis Kuhne’s The Natural Science of Healing were translated into English by Lust and released through his publication house. 

The Convergence With American Influences The Universal Naturopathic Directory was truly eclectic in its compilation and composition. Besides the Lust articles, the volume included “How I became acquainted with nature cure” by Henry Lindlahr, MD, ND (which was reproduced in large part in the introduction to volume 1 of Lindlahr15); “The nature cure” by Carl Strueh, MD, ND; “Naturopathy” by Harry E. Brook, ND; “The present position of naturopathy and allied therapeutic measures in the British Isles” by Allen Pattreiouex, ND; “Why all drugless methods?” by Per Nelson; and “Efficiency in drugless healing” by Edward Earle Purinton (a reprint of the 1917 publication, referred to earlier, which was composed of a series of articles published in The Herald of Health and Naturopath between August 1914 and February 1916). The volume also contained Louis Kuhne’s “Neo-naturopathy (the new science of healing),” in the first publication of the translation by Lust, and articles on electrotherapy, neuropathy, dietology, chiropractic, mechanotherapy, osteopathy, phytotherapy, apyrtropher, physical culture, optometry, hydrotherapy, orthopedics, pathology, natural healing and living, astroscopy, phrenology, and physiology—all of

which were specially commissioned for the directory from practitioners and authors considered expert in these subjects. Also included was a national directory of drugless physicians in alphabetical order, geographically arranged and itemized by profession; biographic notes on American contributors of note; the naturopathic book catalog; a guide to natural healing and natural life books and periodicals; a classified list of medical works; a series of book reviews; a buyer’s guide for naturopathic supplies; and, in addition to extensive indexes, a “parting word” by Lust. The volume contained numerous advertisements for naturopathic schools, sanitariums, and individual practices, and it closed with the following note: This, then, completes Volume 1 of the Naturopathic Directory, Drugless Yearbook and Buyer’s Guide for the years 1918 and 1919. Into it, has been placed the conscientious labor of many willing hearts, hands and minds. It is their contribution to the noble cause of natural healing. It will stand as a monument to their endeavors, as well as a memorial to the great souls, the fathers of natural healing, who have passed on. Let this, then, herald a new era—the era wherein man shall recognize the omniscience of Nature, and shall profit through conforming to her laws. In the biographic sections, it is apparent that Lust owed a great deal of the feeling of camaraderie in the nature cure movement to some varied American practitioners. The most prominent of these had their biographic sections contained in the 1918 directory. Two of them deserve specific note and attention: Palmer and Still. Lust met A. T. Still in 1915 in Kirksville, Missouri, shortly before Still’s death. From their meetings, Lust noted later in the Naturopath and Herald of Health (June 1937) that Still believed that osteopathy by “compromising with medicine is doomed as the school that could have incorporated all the natural and biological healing arts.” Lust wanted naturopathy to fill this void. Lust also had a lengthy acquaintance with B. J. Palmer (the son of D. D. Palmer, the founder of chiropractic), who, following in his father’s footsteps, put Davenport, Iowa, and the Palmer Chiropractic College on the map. Lust also became connected with Henry Lindlahr, MD, ND, of Chicago (as noted in the autobiographical sketch contained in the directory16 and reprinted in volume 1 of Lindlahr15). Lindlahr was a rising businessman in Chicago with all the bad habits of the “gay nineties” era. In his 30s, he became chronically ill. He had gone to the orthodox practitioners of his day and received no relief. Then he was exposed to Schroth’s works, and in following them began to feel somewhat better. Subsequently, he liquidated all his assets and went to a German sanitarium to be cured and to learn nature cure. He returned to Chicago and enrolled in the Homeopathic/Eclectic College of Illinois. In 1903 he opened a sanitarium, which included a residential sanitarium, located in Elmhurst, Illinois; a “transient” clinic (office) on State Street in Chicago; and “Lindlahr’s Health Food Store.” Shortly thereafter, he founded the Lindlahr College of Natural Therapeutics, which included hospital internships at the sanitarium. The institution became one of the leading naturopathic colleges of the day. In 1908 he began to publish Nature Cure Magazine and began publishing his series of Philosophy of Natural Therapeutics, with volume 1 (“Philosophy”) in 1918. This was followed by volume 2 (“Practice”) in 1919; volume 3 (“Dietetics”; republished with revisions as originally published in 1914); and, in 1923, volume 6 (“Iridiagnosis”). The intended volumes 4 and 5 were in production at the time of Lindlahr’s death in 1927. As described in Other Healers, Other Cures17:

CHAPTER 3 

The History of Naturopathic Medicine: Origins and Overview

Henry Lindlahr, another American, is remembered for his conviction that disease did not represent an invasion of molecules, but the body’s way of healing something. In other words, he viewed symptoms as a positive physiological response—proof that the body is fighting whatever’s wrong. Accordingly, a fever is a “healthy” sign and one should be let alone, unless it is dangerously high, of course. The effect of all these gentlemen on the development of naturopathy in America, under Lust’s guidance, was profound. From these beginnings, the naturopathic movement gathered strength and continued to grow through the 1920s and 1930s, having a major effect on natural healing and natural lifestyles in the United States. Along the way, Lust was greatly influenced by the writings of John H. Tilden, MD (largely published between 1915 and 1925). Tilden was originally a practicing physician in Denver who became disenchanted with orthodox medicine and began to rely heavily on dietetics and nutrition, formulating his theories of “auto-intoxication” (the effect of fecal matter remaining too long in the digestive process) and “toxemia.” Lust was also greatly influenced by Elmer Lee, MD, who became a practicing naturopath around 1910 and whose movement was called the “hygienic system,” following the earlier works of Russell Trall. Lee published Health Culture for many years. In addition to John Tilden, MD, and Elmer Lee, MD, another medical doctor, John Harvey Kellogg, MD, who turned to more nutritionally based natural healing concepts, was greatly respected by Lust. Kellogg was renowned through his connection with the Battle Creek Sanitarium. The sanitarium itself was originally founded in the 1860s as a Seventh-Day Adventist institution designed to perpetuate the Grahamite philosophies of Sylvester Graham and William Alcott. The sanitarium was on the verge of being closed, however, because of economic failure, when, in 1876, Kellogg, a new and more dynamic physician-in-chief, was appointed. Kellogg, born in 1852, was a “sickly child” who, at the age of 14, ran across the works of Graham and converted to vegetarianism. At the age of 20, he studied for a term at Trall’s Hygio-Therapeutic College and then earned a medical degree at New York’s Bellevue Medical School. He maintained an affiliation with the regular schools of medicine during his lifetime, due more to his practice of surgery than his beliefs in the area of health care.4 Kellogg designated his concepts, which were basically the hygienic system of healthful living, “biologic living.” Principally, Kellogg defended vegetarianism, attacked sexual misconduct and the evils of alcohol, and was a prolific writer throughout the late 19th century and early 20th century. He produced a popular periodical, Good Health, which continued in existence until 1955. When Kellogg died in 1943 at the age of 91, he had had more than 300,000 patients through the Battle Creek Sanitarium (which he had renamed from the Western Health Reform Institute shortly after his appointment in 1876), including many celebrities, and the “San” became nationally well known. Kellogg, along with Tilden and Elie Metchnikoff (director of the prestigious Pasteur Institute and winner of the 1908 Nobel Prize for a contribution to immunology), wrote prolifically on the theory of auto-intoxication. Kellogg, in particular, felt that humans, in the process of digesting meat, produced various intestinal self-poisons that contributed to auto-intoxication. As a result, Kellogg became a near fanatic on the subject of helping humans return to a more healthy, natural state by returning to the naturally designed usage of the colon. He felt that the average modern colon was devitalized by the combination of sedentary living, the custom of sitting rather than squatting to defecate, and the modern

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civilized habit of ignoring “nature’s call” out of an undue concern for politeness. Further, Kellogg concentrated on the fact that the modern diet had insufficient bulk and roughage to stimulate the bowels to proper action. Kellogg was also extremely interested in hydrotherapy. In the 1890s he established a laboratory at the San to study the clinical applications of hydrotherapy. This led, in 1902, to his writing Rational Hydrotherapy. The preface espoused a philosophy of drugless healing that came to be one of the bases of the hydrotherapy school of medical thought in America. Tilden, as mentioned, was of a similar mind. He must have been to have provided natural healthcare literature with his 200-plus-page dissertation entitled “Constipation,” with a chapter devoted to the evils of not responding when nature called. This belief in the “evils” drawing away from the natural condition of the colon was extremely important to Kellogg’s work.4 Because of Lust’s interest, Kellogg’s The New Dietetics (1921) became one of the bibles of naturopathic literature.18 Lust was also influenced by the works of Sidney Weltmer, the father of “suggestive therapeutics.” The theory behind Professor Weltmer’s work was that whether it was the mind or the body that first lost its grip on health, the two were inseparably related. When the problem originated in the body, the mind nonetheless lost its ability and desire to overcome the disease because the patient “felt sick” and consequently slid further into the diseased state. Alternatively, if the mind first lost its ability and desire to “be healthy” and some physical infirmity followed, the patient was susceptible to being overcome by disease. Weltmer’s work dealt specifically with the psychological process of desiring to be healthy. Lust enthusiastically backed Weltmer’s work and had him appear on the programs at various annual conventions of the American Naturopathic Association (which commenced after its founding in 1919). Lust was also personal friends with and a deep admirer of Bernarr MacFadden.19 MacFadden was the founder of the “physical culture” school of health and healing, also known as “physcultopathy.” This school of healing gave birth across the country to gymnasiums at which exercise programs, designed to allow the individual man or woman to maintain the most perfect state of health and human condition possible, were developed and taught.4 Other Healers, Other Cures described it as follows15: The next Naturopathic star, after Kellogg, was Bernarr MacFadden, the physical culturist who built a magazine-publishing empire (his first magazine was Physical Culture founded in 1898). MacFadden proselytizes for exercise and fresh vegetables, hardly eccentric notions. But his flamboyant efforts to publicize them and his occasional crack-pot ideas (like freezing the unemployed, then thawing them out when the Depression was over) alienated many people. Still, he was his own best advertisement. He fathered nine children by four wives and was parachuting from planes in his 80s. One of MacFadden’s admirers was that arch-foe of the medical profession, George Bernard Shaw, the longevous eccentric in his own right. Lust was also interested in, and helped publicize, “zone therapy,” originated by Joe Shelby Riley, DC, a chiropractor based in Washington, DC, and one of the early practitioners of “broad chiropractic.” Zone therapy was an early forerunner of acupressure as it related “pressures and manipulations of the fingers and tongue, and percussion on the spinal column, according to the relation of the fingers to certain zones of the body.”17 Several other American drugless healers contributed to a broad range of “-opathies” that Lust merged into his growing view of naturopathy as the eclectic compilation of methods of natural healing. The

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Philosophy of Natural Medicine

Universal Directory also contained a complete list of osteopaths and chiropractors as drugless healers within the realm of Lust’s view of naturopathic theory. His other significant compatriots at the time of the publication of the directory were Carl Stueh, described by Lust as “one of the first medical men in this country who gave up medicine and operation for natural healing”; F. W. Collins, MD, DO, DC, an early graduate of the American School of Naturopathy (1907) who went on to graduate from the New Jersey College of Osteopathy (1909) and the Palmer School of Chiropractic (1912); another “broad chiropractor,” Anthony Matijaca, MD, ND, DO, the naturopathic resident expert in electrotherapy and an associate editor of the Herald and Health Naturopath (the inverted name of the Lust journal at the time of the directory); and Carl Schultz, ND, DO, MD, president and general manager of the Naturopathic Institute and Sanatorium of California, essentially the second school in the country to pursue the education of physicians under the name of “naturopathy.” In Inner Hygiene: Constipation and the Pursuit of Health in Modern Society, Whorton20 offered his first assessments of the work of Lust as it related to the emergence of naturopathy in the early 20th century: Most of the drugless clan also identified themselves as practitioners of naturopathy, a system of practice that grew out of hydropathy, as well as German water-cure and nature-cure traditions. Organized in the late 1890s under the leadership of German immigrant Benedict Lust, naturopathy sought to cure the full scope of human ills with natural agents (herbs, water, air, sunlight, electricity, massage, and others), agents that supported and stimulated the body’s own healing mechanisms. In his extensive assessments of Lust’s work and writings in Nature Cures: The History of Alternative Medicine in America, Whorton21 attempted to put the philosophic development of naturopathy in a reasonable historical context: However much a dreamer Lust was in some respects, he was an insightful realist in others. He was correct in believing that simply giving nature support as it ran its course was the best one could do with many diseases in his day. He was correct in seeing self-abuse as the source of much physical, and emotional, suffering and attacked it with an ardor that MDs could not bring to the task until nearly a century later. Recent medical lamentations over the evils of smoking, sexual promiscuity, and other risky behaviors adopted in the thoughtless chase after pleasure have nothing on Lust’s jeremiads … Lust was right in reprimanding allopaths for focusing so strongly on disease as to lose sight of the importance of promoting health. He was right in appreciating the need to “individualize” the treatment of each patient—and in seeing patient self-responsibility as part of that individualization. 

EARLY-20TH-CENTURY MEDICINE The Metamorphosis of Orthodox Medicine Naturopathy’s formative years, and in some respects its halcyon days, were from 1900 to 1917. In many jurisdictions, modern licensing laws were not yet in effect, so varied schools of healing were openly practiced. By 1920, however, the American world of medicine had undergone a sharp transition, culminating in four decades of change. A look at the structure of early medical care in the United States is instructive, even as practiced and dominated by the orthodox school, when noting the changes that occurred between 1875 and 1920. In 1875 the following was descriptive of American medical practice: • The practice, even in urban areas, sent the doctor to the patient; the “house call” was the norm. • There was little modern licensing regulation.

• H  ospitals were charitable institutions where persons too poor to otherwise receive health care were usually sent when ill. • The AMA, although formed in 1846 and generally representative of the professional goals of the regular or orthodox school of medicine, had scarcely begun to make any political inroads at all. • Medical schools required little or no college education for entrance and were largely apprenticeship based and proprietary in nature, having changed little throughout the century. • Although some doctors had begun to specialize, to do so was far from the norm. The major recognized specialties were surgery, obstetrics, and gynecology. • Many different types of doctors existed, and society’s reaction to the profession neither recognized specific expertise nor necessarily rewarded professionals in medical practice well. • Although the orthodox school made up roughly 80% of professional medical practitioners, the homeopaths and the eclectics were visible and respected in their own communities for their abilities and expertise, and much of the public relied on other “irregular” practitioners. By comparison, in 1920, a total metamorphosis of the medical profession had occurred: • By 1920, practices had become office oriented and clinic oriented. • Modern licensing principles had become fully developed, and physicians and surgeons were licensed in all jurisdictions. Most other healthcare providers had some licensing restrictions placed on them, if they were recognized at all. • Due largely to the introduction into surgery of the practice of antiseptic techniques and aseptic procedures and a correspondent decline in operative mortality, institutional care in the hospital became increasingly accepted. Also, clinical pathology and diagnostic laboratory procedures had become well developed, and the hospital had become a major training and clinical research facility that was generally more acceptable to the patient. • The AMA was approaching the peak of its political power, having exercised, through its Council on Medical Education and its Council of Pharmacy and Chemistry, major effects on medical schools and the pharmaceutical industry. • The transition to research- and education-based medical schools, instead of practitioner apprenticeships and proprietary education, had become complete. All recognized medical schools had a 4-year curriculum, with an undergraduate degree or substantial undergraduate study required as a prerequisite. In addition, most schools, in conjunction with most licensing statutes, required a year’s internship. • Specialization was becoming well developed, and the number of specialty groups had increased considerably. This would continue throughout the 1930s and into the early 1940s. • Professional authority and autonomy had undergone a substantial transition, and the allopathic physician was now recognized as a medical expert. • By 1922, the last eclectic school was on the verge of closure, and in the early 1930s, the last of the homeopathic schools in the United States was also on the verge of closure. The influence of these sects on orthodox medicine had dwindled to almost nothing. Naturopaths and other alternative healthcare practitioners had adopted the areas of expertise previously considered the territory of homeopaths and eclectics. 

The Halcyon Years of Naturopathy In 1924 Morris Fishbein succeeded George Simmons as editor of the Journal of the American Medical Association (JAMA). Fishbein had

CHAPTER 3 

The History of Naturopathic Medicine: Origins and Overview

joined the editorial staff of JAMA under Simmons immediately after his graduation from Chicago’s Rush Medical School in 1913. Campion pointed out the following9: Over the years, Fishbein not only established himself as the gifted editor of the most widely read medical journal in the United States; he also learned how to extend his editorial position, how to project his opinions nationwide. He became, as the saying went in those years, a “personality.” TIME referred to him as “the nation’s most ubiquitous, the most widely maligned, and perhaps most influential medico.” In addition to his development of JAMA as an editorial and personal voice, Fishbein also continually railed against “quackery.” Lust, among others, including MacFadden, became Fishbein’s epitome of quackery. When MacFadden became a wealthy man, after his publishing company included popular magazines like True Confessions and True Detective, he began campaigning for the 1936 Republican presidential nomination. In response, a physician submitted, under the initials “K.G.,” a tongue-in-cheek listing of the cabinet that would exist under MacFadden, including the newly created “Secretary of Aviation” for Lust. Lust was a popular figure by this time who conducted such a busy lecture schedule and practice, alternating between the “Yungborns” in Butler, New Jersey, and Tangerine, Florida, that he had become almost as well known as an airline traveler. Lust devoted a complete editorial in Nature’s Path to a response. Although Fishbein had JAMA as a personal editorial outlet, Lust had his own publications. Commencing with the Naturopath and Herald of Health in 1902 (which changed its name to Herald of Health and Naturopath in 1918), Lust continually published this and other monthly journals. In 1919 it became the official journal of the ANA, mailed to all members. Each edition contained the editorial column “Dr. Lust Speaking.” In the early 1920s, the “health fad” movement was reaching its peak in terms of public awareness and interest. As described, somewhat wistfully, in his June 1937 column, Lust announced the approach of the 41st Congress of Natural Healing under his guidance: The progress of our movement could be observed in our wonderful congresses, in 1914 Butler, N.J., 1915 Atlantic City, 1916 in Chicago, 1917 Cleveland, 1918 New York, 1919 Philadelphia, 1920 and 1921 again New York, and 1922 in Washington, D.C., where we had the full support and backing of the Congress of the United States. President Harding received the president and the delegates of our convention and we were the guests of the City of Washington. Through the strenuous efforts of Dr. T.M. Schippel, Hon. Congresswoman Catherine Langley of Kentucky, and eight years of hard work financed and sustained by Dr. Schippel and her powerful friends in Congress, Naturopathy was fully legalized as a healing art in the District of Columbia and the definition was placed on record and the law affirmed and amended by another act which has been fully published over and over again in the official journal of the A.N.A., Naturopath. In 1923 in Chicago, with the help and financing of the great and never-to-be forgotten Dr. Henry Lindlahr, we had a great convention. Not only were all the Naturopaths there but even to an extent our congress was recognized and acknowledged as official and of great importance by the medical people, particularly by the Health Commissioner of Chicago. We held a banquet, and there were discussions covering all platforms of the healing art. It was the first congress in the United States where medicine and Naturopathy in all its branches such as the general old-time Nature Cure, Hydrotherapy and Diet, Osteopathy, Naprapathy, Chiropractic,

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Neuropathy and Physiotherapy were represented on the same platform. The speakers represented every modern school of healing and the movement at that time was in the direction of an entirely recognized and independent school of healing. There were two camps, official medicine and official Naturopathy, the medical camp having all that is good and bad in medicine and surgery and all the other schools of healing that had sold their birthright and trusted to the allurement of organized medicine, such as Homeopaths, Eclectics, Physio-medics, and the Osteopaths to a large extent. The Osteopaths were always in the wrong camp when they went on mixed boards and Dr. Andrew Taylor Still, the father of Osteopathy, told me in 1915 that by compromising with medicine Osteopathy is doomed as the school that could have incorporated all of the natural and biological healing arts. The year following we had the great congress in Los Angeles which has never been duplicated. We had to meet in two hotels because the crowds ran over 10,000. The glorious banquet will never be forgotten and the congress celebrated and demonstrated that the initial and first intent of the A.N.A. to teach the public Natural Living and Nature Cure was realized. We will never forget the glorious week in Los Angeles where the authorities and the whole city joined us. The success of that congress was largely due to the talent of Dr. Fred Hirsch, the successor to Prof. Arnold Ehret and the noble and generous Naturopaths of the A.N.A. of Cal. There was never a second congress like that. Then we had the great congresses of New York in 1925, Indianapolis 1926, Philadelphia 1927, Minneapolis 1928, Portland, Oregon 1929, New York 1930, Milwaukee 1931, Washington, D.C., 1932, Chicago 1933, Denver 1934, San Diego 1935, and Omaha 1936. In 1925 Lust began to try to reach more of the general populace through the lay publication Nature’s Path. The Naturopath and Nature’s Path were later merged because the self-supporting advertising and subscription monies were more available by publication to the general populace than to the members of the association (The Naturopath, 1902–1927; Nature’s Path, 1925–1927; merged 1927–1933; separated 1934–1938; Nature’s Path, 1939–1945). How large a professional movement Lust inspired during this period of naturopathy’s emergence is difficult to gauge. An extensive government survey was not undertaken until 1965. However, as Whorton described in Nature Cures,21 naturopathy had an effect: Those were messages that had enough appeal, evidently, to allow naturopathy to expand steadily through the first decades of the century until by 1923 Lust could estimate that there were nine thousand naturopaths, a “vast army of professional men and women” working on all continents to “rejuvenate and regenerate the world.” His figures were undoubtedly inflated. An independent study [the work of the CCMC discussed later] put the number of naturopaths at “possibly 1500,” allowing that if the “allied groups” that advocated drugless healing under other names [physiotherapy, sanipractic] were added on the total may reach 2500. Yet whatever their numbers, naturopaths had grown into a force not to be ignored. Although Lust’s claim of 9000 naturopaths worldwide is impossible to assess, 5000 practitioners may be a reasonable estimate of the reach of his naturopathy in the United States by the late 1920s and into the 1930s. As Whorton21 reported, the mixer orientation within chiropractic was also becoming a growing presence. This orientation was a philosophy that tended to merge chiropractic and naturopathy in education and practice.22 Although homeopathy has undergone a small revival in recent years, very few MDs now practice it. It is currently mainly of interest to naturopaths, who earn doctor of naturopathy (ND) degrees, and to a few chiropractors. Naturopaths closely resemble

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SECTION 1 

Philosophy of Natural Medicine

chiropractors in that they use spinal manipulative therapy and because so-called mixer chiropractors also use naturopathic methods such as heat, cold, hydrotherapy, physiotherapy, dietary supplements, and even some herbal and homeopathic remedies, which is why the traditional, or “straight,” chiropractors disparagingly call them “medipractors.” Until the middle of the 20th century, a few mixer schools offered both DC and ND degrees, either as alternatives or together after an additional semester of study. Whorton noted a “1930 survey in which some 1,800 chiropractors participated, found, for example, that 1,124 employed hydrotherapy, 1,173 used light therapy, 1,257 provided electrotherapy, and a full 1,352 trusted vibration therapy.”21 In January 1934 Lust commenced republication of the title Naturopath and Herald of Health in addition to Nature’s Path. Each volume opened with his personal column, different for each publication. Both publications were issued through 1938, when the Nature’s Path again became the sole publication until Lust’s death in 1945. After the Universal Directory, Lust continued to write volumes on naturopathic principles, although he was more of a synthesizer, organizer, lecturer, and essayist than a scientific documenter of naturopathic principles. His most enduring contributions may remain his early translations of Kuhne’s and Just’s works. During the 1920s and up until 1937, Lust’s brand of “quackery,” so labeled by Fishbein, was in its most popular phase. Although the institutional markings of the orthodox school had gained ascendancy, before 1937, it had no real therapeutic success in the treatment of disease outside of the broad advancements in public health. Lust’s naturopathy, together with chiropractic and osteopathy, continued to be on the outside looking in, this lack of therapeutic advancement notwithstanding. Practitioners of all three movements were continually prosecuted for practicing medicine without a license, although they often won their cases by establishing to juries that their practices were (even according to the testimony of medical men) not the same as medicine at all. At the time, orthodox practitioners could offer little or no expectation of cure for many diseases, and the “health food and natural health” movement was generally popular. During the 1920s Gaylord Hauser, later to become the health food guru of the Hollywood set, came to Lust as a seriously ill young man. Lust, through the application of the nature cure, removed Hauser’s afflictions and was rewarded by Hauser’s lifelong devotion. His regular columns in Nature’s Path became widely read among the Hollywood set. As noted in Other Healers, Other Cures15: The last big name in Naturopathy was Gaylord Hauser, a Viennese-Born food scientist (as one of his early books identified him) turned to Naturopathy in his later years. He is best remembered for advising the eating of living foods, not dead foods, and for escorting Greta Garbo around. In addition to fresh fruits and vegetables, Hauser’s “Wonder Foods” were skimmed milk, brewer’s yeast, wheat germ, yogurt, and blackstrap molasses. The naturopathic journals of the 1920s and 1930s are instructive. Much of the dietary advice focused on poor eating habits, including the lack of fiber in the diet and an overreliance on red meat as a protein source. More than half a century later in the 1980s, the pronouncements of the orthodox profession, the National Institute of Health, and the National Cancer Institute finally accepted the validity of these early assertions by naturopaths that poor dietary and living habits (particularly smoking) would lead to degenerative diseases, including cancers associated with the lungs, the digestive tract, and the colon. The December 1928 volume of Nature’s Path was the first American publication of the works of Herman J. DeWolff, a Dutch epidemiologist who was one of the first individuals to assert, based on studies of

the incidence of cancer in the Netherlands, that there was a correlation between exposure to petrochemicals and various types of cancers. He saw a connection between chemical fertilizers and their usage in some soils (principally clay) that led to poisons remaining in vegetables after they had arrived at the market and were purchased for consumption. Again, it was 50 years before orthodox medicine began to accept the wisdom of such concerns. As Whorton noted in Nature Cures, naturopaths were less successful than osteopaths and chiropractors in accomplishing professionalization by the elevation of professional standards, including professional education. This occurred despite the formation of a National Board of Naturopathic Examiners of the ANA in 1940. There was constant internal bickering, which “by the 1940s had taken on a more ominous tone.” Although “standards at naturopathic schools were steadily raised from the 1940s on, thanks to both professional idealism and the requirements of state licensing laws,” based on “a perusal of the statutes of the dozen states in which naturopaths were licensed in the late 1940s,” the divisive trends within naturopathy “would not begin to be reversed until the 1970s.” Whorton21 observed that there was no misunderstanding where Lust himself stood on the need for professional standards: Obtaining their own licensing statutes was perceived by alternative practitioners as a critical measure for purging incompetence and quackery from their own rank. “Where there is no official recognition and regulation,” the founder of naturopathy, Benedict Lust maintained, “you will find the plotters, the thieves, the charlatans … [The] riff-raff opportunists bring the whole art into disrepute.” By the time Lust said this, shortly before his death in 1945, frustrating experience had demonstrated that “that is the fate of any science—any profession—which the unjust laws have placed beyond the pale.” In following the evolution of alternative medicine over the first third of the twentieth century, it is essential to keep in mind that constant battle of each system to bring itself within the pale. 

The Emerging Dominance of American Medical Association Medicine In 1937 the status of conventional (allopathic) medicine began to change. The change came with the beginning of the era of “miracle medicine.” Lewis Thomas, in his interesting work The Youngest Science,23 compared his education and internship as a physician with his father’s life as a physician. His father believed that bedside manner was more important than any actual medication offered by the physician. His father went into general surgery so that he could offer some service to his patients that actually made some change in their condition. Thomas pointed out that the major growth of “scientific medicine” until 1937 advanced diagnosis rather than offering any hope of cure. This introduction of “miracle medicine,” the social effects of World War II on health care, and the death of Lust in 1945 all combined to contribute a precipitous decline for naturopathy and natural healing in the United States. (During the war, the necessity for crisis surgical intervention techniques for battlefront conditions encouraged the use of morphine, sulfa drugs, and penicillin for diseases not previously encountered in civilian life by American combat soldiers. This resulted in the rapid development of higher-technology approaches to medicine and highly visible successes.) Lust recognized this, and his editorializing became, if anything, even more strident. From the introduction of sulfa drugs in 1937 to the Salk vaccine’s release in 1955, the American public became used to annual developments of miracle vaccines and antibiotics.

CHAPTER 3 

The History of Naturopathic Medicine: Origins and Overview

Lust died in September 1945 at the Yungborn facility in Butler, New Jersey, preparing to attend the 49th Annual Congress of his American ANA. In August 1945, for the official program of that congress held in October 1945 just after his death, he dictated the following remarks: What is the present condition of Naturopathy? What is its future? I can give my opinion in a very few words. For fifty years I have been in the thick of the fight to bring to the American people the Nature Cure. During that period I have had an opportunity to judge what Naturopathy has done, and can accomplish and the type of men and women, past and present, who make up the Naturopathic ranks. Let us take the present situation first. What is Naturopathy accomplishing? The answer to that is: “Everything.” Naturopathy holds the key for the prevention, alleviation and cure of every ailment, to man and beast alike. It has never failed in the hands of a competent Naturopath. Whatever the body can “catch”—that same body, with proper handling, can eliminate. And that takes in cancer, tumors, arthritis, cataract and the whole gamut of “incurable medical” disease and ailments. During my years of practice I, personally, have seen every type of human ailment and so-called serious “disease” give way to the simple, proven Naturopathic methods. I make no exception to that statement. Now let us see the type of men and women who are the Naturopaths of today. Many of them are fine, upstanding individuals, believing fully in the effectiveness of their chosen profession— willing to give their all for the sake of alleviating human suffering and ready to fight for their rights to the last ditch. More power to them! But there are others who claim to be Naturopaths who are woeful misfits. Yes, and there are outright fakers and cheats masking as Naturopaths. That is the fate of any science—any profession—which the unjust laws have placed beyond the pale. Where there is no official recognition and regulation, you will find the plotters, the thieves, the charlatans operating on the same basis as the conscientious practitioners. And these riff-raff opportunists bring the whole art into disrepute. Frankly such conditions cannot be remedied until suitable safeguards are erected by law, or by the profession itself, around the practice of Naturopathy. That will come in time. Now let us look at the future. What do we see? The gradual recognition of this true healing art—not only because of the efforts of the present conscientious practitioners but because of the bungling, asinine mistakes of orthodox medicine—Naturopathy’s greatest enemy. The fiasco of the sulpha drugs as emphasized disastrously in our armed forces is just one straw in the wind. The murderous Schick test—that deadly “prevention” of diphtheria—is another. All these medical crimes are steadily piling up. They are slowly, but inevitably, creating a public distrust in all things medical. This increasing lack of confidence in the infallibility of Modern Medicine will eventually make itself felt to such an extent that the man on the street will turn upon these self-constituted oppressors and not only demand but force a change. I may not be here to witness this revolution but I believe with all my soul that it is coming. Yes, the future of Naturopathy is indeed bright. It merely requires that each and every true Naturopath carry on—carry on—to the best of his and her abilities. May God bless you all. The effects of postwar events on osteopathy and chiropractic were completely different from the effect on naturopathy. In the early days of osteopathy, there was a significant split between the strict drugless system advocated by A. T. Still (osteopathy’s originator) and the beliefs of many MDs who converted to osteopathy because of its

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therapeutic value. The latter group did not want to abandon all of the techniques they had previously learned and all of the drugs they had previously used when those therapy techniques were sometimes effective. Ultimately, most schools of osteopathy, commencing with the school based in Los Angeles, converted to more of an imitation of modern orthodox medicine. These developments led to more of an accommodation between the California osteopaths and the members of the California Medical Association. (This developing cooperation between the California Osteopathic and Medical Association was one of the major issues leading to the downfall, in 1949, of Fishbein’s editorial voice in JAMA.) Thus osteopathy found a place in professional medicine, at the cost of its drugless healing roots and therapies.9 Naturopathy had become an element of chiropractic education and practice at least as early as 1910 with the founding of the Peerless College of Chiropractic and Naturopathy in Portland, Oregon.22 From this point on, naturopathic education developed in two tracks: schools of naturopathy owned and operated by naturopaths and chiropractic schools that had naturopathic curricula in addition to the core chiropractic programs. These latter schools were a central part of the mixer orientation within chiropractic.22,24 Initial assessments of schools of naturopathy occurred in the 1920s and 1930s. These assessments came from those within, or allied with, allopathy and were therefore hardly unbiased, but much of the information in these assessments seemed credible. The progression of education in naturopathy would be expected to have been similar to that of chiropractic, if somewhat smaller in scale. In this regard, Wardwell noted22: Wiese and Ferguson25 identified 392 different chiropractic schools as having existed in the United States. When those for which there is no evidence of more than a year of operation are eliminated, the number is reduced to 188. Most of them probably produced few graduates—the number of schools increased rapidly to their largest between 1910 and 1926, and then contracted, particularly during the depression of the 1930s and World War II. The history of schools of naturopathy followed much the same pattern. Whorton21 noted in Nature Cures that this was the case. The operators of these schools seemed, at least on the surface, aware of the kind of criticisms to which proprietary trade and professional schools were subjected: limited facilities, limited resources, and an emphasis on collecting revenue versus providing a full professional education.22,24 The leading operators of schools of naturopathy sought, at least on paper, to respond to these criticisms. By letter agreement dated October 7, 1922, four of the most identifiable leaders of naturopathy—Benedict Lust, Joe Shelby Riley, F. W. Collins, and Henry Lindlahr—committed to the formation of the Associated Naturopathic Schools and Colleges of America and committed themselves, as “the Presidents of Naturopathic Schools in the United States of America,” to specific educational minimums “on and after January 2, 1923”: “all matriculants must have a primary school education26 and all naturopath courses must be composed of 4 years of 6 months each.” Additionally, the letter provided that “time allowance or credits may be given to practitioners in the field who desire to take up the naturopathic courses, and to licensed physicians of other methods of healing,” with the amount of such credit being left to each school’s discretion. In the summer and fall of 1927 representatives of the AMA’s Council on Medical Education and Hospitals conducted inspections—unannounced and incognito—of schools of “chiropody, chiropractic, naturopathy, optometry, osteopathy, physical therapy, as well as a large number of institutions.” From these inspections, several reports were generated, including the Council’s report on “Schools of Chiropractic and Naturopathy in the United States,”

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SECTION 1 

Philosophy of Natural Medicine

which appeared first as part of the Council’s Annual Report, 1928, and later as reprinted in JAMA. The report identified 40 schools of chiropractic and 10 schools of naturopathy and detailed the inspections of “some schools of Chiropractic and of Naturopathy”: Palmer School of Chiropractic (a straight school); National College of Chiropractic (a mixer school that was reported as having recently purchased and assimilated Lindlahr College of Natural Therapeutics); Los Angeles College of Chiropractic (another leading mixer school); the combined American School of Naturopathy, Inc. and American School of Chiropractic, Inc. (Lust’s own New York City schools, although Lust was observed to have been “in Florida” at the time of the inspections); and the Naturopathic College and Hospital of Philadelphia. The reports were predictably negative with regard to facilities, resources, and the clearly proprietary nature of the establishments. Louis Reed of the Committee on the Costs of Medical Care (CCMC), in discussing “naturopathic schools,”24 relied heavily on this report from the AMA’s Council and observed that “in 1927, according to the American Medical Association, there existed twelve naturopathic colleges with not over 200 students. These figures would probably hold good for the present time.” Reed also concluded that there were “a considerable number of miscellaneous drugless healers of a type similar to chiropractors practice in this country” as of 1932 and that “the naturopaths form the largest group of these practitioners.… Of these various cults, only the naturopaths and the sanipractors have any considerable membership. Many of the (other) cults are really part of the naturopathic group.”24 As to numbers of drugless practitioners, Reed observed that “only the roughest estimate can be made—probably there are about 2500,” of which naturopaths “number possibly 1500,” and sanipractors—“only the name distinguishes sanipractors from the naturopaths”—numbered some 500 in their Washington state “stronghold.” Reed also observed that as of 1932: “A few states—Connecticut, Florida, Oregon, South Carolina, Utah, Washington and the District of Columbia—provide for licensing of naturopaths as limited practitioners.… In addition to those mentioned, certain states (Alabama, Colorado, Illinois, Indiana, Michigan, Ohio, Pennsylvania, New Jersey, and Wyoming) make (other) provision for the licensing of drugless or limited practitioners.”24 Reed’s work for the CCMC, although clearly biased against all of the healing philosophies he identified as “medical cults” (a la Fishbein), principally osteopathy, chiropractic, and naturopathy, was the only work that attempted to survey the presence and effect of these schools of healing in the United States in the 1920s and 1930s.27 A decade later, in April 1945, another work of this kind appeared in the Rhode Island Medical Journal. The article, “Naturopathic Legislation and Education,” was written by the Rhode Island Medical Society’s executive secretary, John E. Farrell, to set out some of the society’s reasons for opposing legislation that would license naturopathy in Rhode Island. The article noted that according to the 1942–1943 Report of the Committee on Education of the ANA, 13 schools of naturopathy in the United States met the criteria of the ANA; the article went on to make a lengthy “Report on Schools” through visits to most of the identified schools.28 The predictable criticisms of these schools as underfinanced, underresourced, and proprietary in nature appeared once again, although by actual detail of description, National College (Chicago) and Western States (Portland) seemed to be well-established, functioning mixer schools of chiropractic and naturopathy. The effect on chiropractic of the post–World War II years was somewhat different. Because of educational recognition under the G.I. Bill, the number of chiropractors in the country grew

substantially, and their effect on the populace grew accordingly. The sect eventually grew powerful enough in terms of numbers and economic clout that it could pose a legal challenge to the orthodox monopoly of the AMA. However, in the immediate postwar years, the AMA gained tremendous political clout. Combined with the American Legion and the National Board of Realtors,29 these three groups posed a powerful political triumvirate before the U.S. Congress. These years, called the years of the “great fear” in Caute’s book by that name,30 were the years during which to be unorthodox was to be “un-American.” Across the country, courts began to take the view that naturopaths were not truly doctors because they espoused doctrines from “the dark ages of medicine” (something American medicine had apparently come out of in 1937) and that drugless healers were intended by law to operate without “drugs” (which became defined as anything a person would ingest or apply externally for any remedial medical purpose). In this regard, the Washington State Supreme Court case of Kelly v. Carroll31 and the Arizona State Supreme Court case of Kuts-Cheraux v. Wilson document how significant limitations were placed on naturopaths under the guise of calling them “drugless healers.” In the state of Tennessee, as a reaction to the 1939 publication of the book Back to Eden by herbalist Jethro Kloss, court action initiated by the Tennessee State Medical Association led first to the publishers being forbidden to advertise the book for any therapeutic purpose. They were allowed only to acknowledge that it was in stock. Then, after a serious licensing scandal during the war years, the Tennessee State Legislature declared the practice of naturopathy in the state of Tennessee to be a gross misdemeanor, punishable by up to 1 year in jail. Although it was under considerable public pressure in those years, the ANA undertook some of its most scholarly work, coordinating all the systems of naturopathy under commission. This resulted in the publication of a basic textbook on naturopathy (Basic Naturopathy, published in 1948 by the ANA32) and a significant work compiling all the known theories of botanical medicine (as commissioned by the ANA’s successor after its 1950 name change to the American Naturopathic Physicians and Surgeons Association), the Naturae Medicina, published in 1953.33 Naturopathic medicine began splintering when Lust’s ANA was succeeded by six different organizations in the mid-1950s. The primary organizations among these were the successor to the ANA, which underwent a name change in 1950 to the American Naturopathic Physician and Surgeon’s Association and subsequently changed to the American Association of Naturopathic Physicians (AANP) in 1956, and the International Society of Naturopathic Physicians formed under the leadership of M. T. Campenella of Florida shortly after Lust’s death, with its American offshoot, the National Association of Naturopathic Physicians. In the face of the AMA’s determination to eliminate chiropractic, and with it, naturopathy—healing philosophies that were linked through the mixer orientation within chiropractic (during the 1930s and through the 1960s the majority camp within a divided chiropractic)—naturopathy went through a period of decline described by Hans Baer (see Bibliography). Walter Wardwell was a sociology professor who became an early leader in what developed as a subspecialty in the 1950s: medical sociology. His earliest work, starting with his doctoral dissertation (1951) at Harvard, focused on chiropractic as an example of a marginalized health profession (see Bibliography). As early as his doctoral dissertation, Wardwell discussed naturopathy as an adjunct discipline to

CHAPTER 3 

The History of Naturopathic Medicine: Origins and Overview

chiropractic in the context of the continuing division of chiropractic into mixers and straights. As he later noted34: Comparison of the survival of chiropractic with that of osteopathy and naturopathy is a quite different matter which does not involve metaphysical or epistemological differences between them. Furthermore, the overlap in theory between chiropractic, osteopathy and naturopathy is very great. Differences between osteopathic and chiropractic manipulative treatment appear to be more a matter of who applies the technique rather than differences in technique itself. The distinction between chiropractors and naturopaths is even more blurred because they often trained at the same schools and sometimes they studied both fields simultaneously. As recently as 1948, three of the currently accredited chiropractic colleges offered N.D. (Doctor of Naturopathy) and D.C. (Doctor of Chiropractic) degrees. In this context he described naturopathy as a school of healing that became extinct as two historical factors converged: the death of Lust in 1945, leaving naturopathy without its “founder,” and the mandate in the early 1950s by the major mixers’ professional group, the National Chiropractic Association (NCA), that it would no longer accredit chiropractic schools that granted degrees in naturopathy: In the case of naturopathy, chiropractic’s victory is nearly complete. Although there may still be up to 2000 naturopaths in practice35 with naturopaths licensed in a few states, and one small school in Portland, Oregon, still offers naturopathic degrees, none of the schools that formerly offered both chiropractic and naturopathic degrees currently does so. With practically no new recruits entering the profession, naturopathy must disappear. By the late 1970s, Wardwell had learned of efforts in the Pacific Northwest to keep naturopathy alive. In his chapter in the Handbook of Medical Sociology, Wardwell noted this presence in the Northwest (which had received no mention in the first two editions in 1963 and 1972)36: The accrediting of chiropractic colleges is encouraging uniformity, not only in curricula but in scope of practice. Those colleges that formerly offered the Doctor of Naturopathy (N.D.) as well as the D.C. degree have ceased doing so, leaving naturopathy with only one remaining small college in Portland, Oregon. In his masterwork, Chiropractic: History and Evolution of a New Profession (1992),22 Wardwell devoted substantial attention to the effect of naturopathy on the mixer orientation within chiropractic and traced naturopathy’s final educational decline to the untimely death in 1954 of William A. Budden, DC, ND, the president of the Western States Chiropractic College (WSCC; Portland, Oregon). After Budden’s death, the WSCC continued to teach naturopathy until 1958 but dropped its ND degree program in 1956. This was the last resistance to the position of the accrediting committee of the NCA, and no chiropractic ND programs remained. Wardwell observed, though, that the seeds of a naturopathic reemergence had been planted in the Northwest after Budden’s death and that naturopathy might survive. The last ND diplomas were granted at the WSCC in 1958 to students who were enrolled in the ND program at the time of Budden’s death. Brinker37 noted the following: Political pressure from the chiropractic profession had begun in the late 1940s to force chiropractic schools to relinquish programs granting naturopathic degrees. After threatening loss of accreditation, the National Chiropractic Association finally forced Western States College to drop its School of Naturopathy in 1956, and it became exclusively Western States Chiropractic College.

43

Efforts to keep naturopathy alive through education and licensure were examined by two reports prepared in 1958, a time when the Utah legislature was reexamining naturopathy’s licensure in the aftermath of a case from the Utah Supreme Court that had dealt its practicing NDs a crippling blow. The first was A Study of the Healing Arts With a Particular Emphasis Upon Naturopathy (November 1958), prepared as “A Report to the Utah Legislative Council” by legislative council staff. As part of its work, the staff conducted inquiries of and site visits to seven schools accredited by the Utah Naturopathy Examining Board as of August 1957. Separately, the Bureau of Economic and Business Research38 of the University of Utah (BEBR) undertook a study focusing on schools that had granted naturopathy degrees and produced Survey of Naturopathic Schools (“Prepared for the Utah State Medical Society,” December 1958). Preparation of the study was, as noted in the title, undertaken by the university research program at the request of the state medical society, but the preparation of the study was independent, and “no attempt was made by that group to influence the results of the study” (Foreword and Acknowledgements). The BEBR study, done with the requested cooperation of investigators from five other universities located in various sections of the United States, surveyed all of the schools listed by Utah licensees as schools of graduation or schools attended, using records maintained by the Utah Department of Business Registration.10 Because the state of naturopathic education in the 1950s is relevant, some observations from this study are worth noting39: One of the most important results to emerge from this study is that there are virtually no schools now teaching naturopathy. Of the 26 schools investigated during this study, only 9 were still in existence in the fall of 1958. Of these nine, only three are now granting naturopathic degrees, and two others are teaching naturopathy. Of the three schools granting ND degrees, the study found that one school, Sierra States University in California, began offering a “postgraduate” ND degree after the most highly respected chiropractic program in the country, Los Angeles College of Chiropractic, had discontinued its ND degree program in 1948. National College of Naturopathic Medicine (NCNM), the Oregon school, had—in 1957, its first year of operation—four ND students who were starting at NCNM and 60 enrolled “postgraduate” DCs pursuing ND degrees. The school had been recognized by the Utah examining board but had not yet granted degrees. The third school granting ND degrees as of 1957 to 1958 was the Central States College of Physiatrics in Eaton, Ohio, essentially the one-man operation of H. Riley Spitler, author of Basic Naturopathy (published by the ANA in 1948). This school granted a doctor of mechanotherapy (DM) degree, recognized in only Ohio and Alabama by law, or an ND degree to anyone who sought licensure in a state where an ND degree would qualify a graduate for licensure. The course of study for both degrees was the same, and the school had graduated 10 students in the previous 2 years. Its ND degrees were recognized in Utah. By 1955, the AANP, as it ultimately became known, had recognized only two schools of naturopathic medicine, the Central States College of Physiatrics in Eaton, Ohio, under the leadership of H. Riley Spitler, and Western States College of Chiropractic and Naturopathy located outside Portland, Oregon, under the leadership of W. A. Budden. Budden was a Lindlahr graduate and among the group that took over control of the Lindlahr College after Lindlahr’s death in the 1920s. He moved west in 1929 when the northwestern states, including Oregon, became a bastion for naturopaths in this country.

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This state of affairs was accurately described by Homola40 in his book on the history and evolution of chiropractic: As of 1958, only five states (Arizona, Connecticut, Oregon, Virginia and Utah) separately classified and provided licensing provisions for the naturopath. A few states, however, did permit licensing of drugless healers following examination by [a] board. (A good number of states have repealed their laws licensing naturopaths in recent years.) Chiropractic schools that employ the use of physiotherapy teach a course that is very similar to the practice of naturopathy. Likewise, the three or four naturopathic schools still operating today have a curriculum similar to that of many chiropractic colleges. In fact, at least four chiropractic colleges awarded naturopathic degrees along with the chiropractic degree before they came under the jurisdiction of the national Chiropractic Association. With the approval of this organization, the schools were prohibited from issuing naturopathic degrees. This practically amounted to a death-dealing blow to the profession of naturopathy.40 In 1967 the U.S. Department of Health, Education, and Welfare; the Public Health Service; and the National Center for Health Statistics (NCHS) published Public Health Service Publication No. 1758, State Licensing of Health Occupations. With the assistance of the Council of State Governments, the NCHS collected data regarding the licensure of health professionals at the state level. “Chapter 8: Naturopaths” recorded the available data for the naturopathic profession as of the mid-1960s. In summary, the NCHS identified five states and the District of Columbia as licensing naturopaths as of 1967: Arizona, Connecticut, Hawaii, Oregon, and Utah. California and Florida were identified as renewing existing licenses but granting no new licenses. The publication reported that by 1965, California had renewed 66 licenses and Florida, 136. Licenses in effect by state were as follows: Arizona (100), Connecticut (47), Hawaii (14), Oregon (148), and Utah (42). No numbers were provided for the District of Columbia. The report stated the following41: In addition to Doctors of Naturopathy (ND) there are other limited branches of medicine; these have not been included in the study. In the State of Washington the Drugless Therapeutics Examining Committee functions (for such licensure). The Ohio law states which branches are to be specified on certificates issued by the State Medical Board to limited practitioners. No attempt has been made to collect information on these drugless healers who are few in number. Active state practitioners were also numbered (although the reason for the differentiation is not clear), as follows: Arizona (53), Connecticut (29), Hawaii (13), and Oregon (121). Given the existence of approximately 50 practitioners at the time in Washington, and some practicing in Idaho under a decision of the Idaho Supreme Court, there appear to have been perhaps as many as 600 to 700 remaining naturopaths practicing at the end of the 1960s.42 According to documentation provided to the federal Department of Health, Education, and Welfare in 1968 by the again-remaining professional association—the National Association of Naturopathic Physicians—only 17 degrees were granted from 1960 to 1968. By 1968, this association had 168 members and estimated that there were perhaps 500 “active” naturopaths in the United States. Congress adopted Medicare in 1965. The legislation covered payment for the services of physicians (essentially MDs and DOs), hospital services, and “other therapeutic services” that would commonly be provided

through these conventional means. As Wardwell reported,22 in 1967, Congress directed the secretary of the Department of Health, Education, and Welfare (HEW), Wilbur Cohen, to study the inclusion services of “additional types of licensed practitioners.” The surgeon general and other HEW staff prepared the resulting Independent Practitioners Under Medicare using advisory committees only (Wardwell served on the Expert Review Committee for Chiropractic and Naturopathy), which actually had little input. This report documented the ebb tide of naturopathy’s “period of decline,” as Baer later labeled it.43 The section of the report Naturopathy concluded that as of 1968: Naturopathic theory and practice are not based on the body of basic knowledge related to health, disease, and health care which has been widely accepted by the scientific community. Moreover, irrespective of its theory, the scope and quality of naturopathic education do not prepare the practitioner to make an adequate diagnosis and provide adequate treatment. Considering the state of the profession in 1968, these negative assessments were hardly unexpected. 

THE MODERN REJUVENATION After the counterculture years of the late 1960s and feeding of an American disenchantment with organized medicine that began after the miracle-drug era faded, exposing some of orthodox medicine’s limitations, alternative medicine began to gain new respect. Naturopathic medicine underwent an era of rejuvenation as a late-1970s consumer interest in more “holistic” medicine began to emerge. As succinctly described in Cassedy’s44 Medicine in America: A Short History, this phenomenon, which was not limited to naturopathic medicine, was consistent with the modern and continuing “search for health beyond orthodox medicine”: It should not have been surprising to anyone that certain organized therapeutic sects continue to exist in mid–twentieth century America as successful and conspicuous alternatives to regular medicine. This is not to say that they offer the same threats to the medical establishment or play the same roles as their nineteenth-century counterparts had, as complete therapeutic systems. But they do continue to hold a strong collective appeal for individuals who mistrust or are somehow disenchanted with mainline medicine. They have appealed also to antiauthoritarian sentiments that flourish throughout society. Moreover, as earlier, they satisfy various needs that regular medicine continues to neglect or ignore. The same author, in describing the post–World War II decades and the changing fortunes of such healing theories as naturopathic medicine, observed as follows: The period also brought about the renewal or updating of certain previously widely used therapies and considerable experimentation with others, some of them exotic. To an extent this trend represented the rediscovery by trained physicians, nurses, and other regular health professionals of certain values and older styles of therapy. The participation of such professionals proved to be an essential ingredient in the rebirth of several such therapies. However, the major reason for the new successes was the wide-spread active interest and involvement of America’s literate lay people in the search for more personal or humane forms of treatment. As another author, John Duffy,45 observed in From Humors to Medical Science:

CHAPTER 3 

The History of Naturopathic Medicine: Origins and Overview

Since health is too closely related to cultural, social, and economic factors to be left exclusively to doctors, American lay people have always engaged in do-it-yourself medicine, resorted to “irregulars and quacks,” and supported health movements. As a result of the current fad for physical fitness, our streets are beset by sweat-suited individuals of all ages doggedly jogging their way to health and long life. In addition, stores selling “natural” foods are flourishing, physical fitness salons have become a major business, and anti-smoking and weight-loss clinics and workshops are attracting thousands of individuals bent on leading cleaner and leaner lives. And those for whom physical activity in itself is not enough are seeking physical and mental well-being through faith healing, yoga, and a host of major and minor gurus. When neither mental effort nor physical exercise can solve medical problems, the sceptics of modern medicine can always turn to the irregulars. A recent estimate places a number of Americans who have relied on an irregular practitioner at some time in their lives at 60 million, and, aided by the high cost of orthodox medicine, irregular medical practice appears to be on the rise. At the beginning of this period of rejuvenation, the profession’s educational institutions had dwindled to one, the National College of Naturopathic Medicine (which had branches in Seattle, Washington, and Portland, Oregon), which was founded after the death of R. A. Budden and the conversion of Western States College to a straight school of chiropractic. Kruger’s15 book Other Healers, Other Cures described it as follows in 1974: Today, Naturopaths in seventeen states are licensed to diagnose, treat, and prescribe for any human disease through the use of air, light, heat, herbs, nutrition, electrotherapy, physiotherapy, manipulations, and minor surgery. At present, one can earn an D.N. [a misnomer, actually—N.D.] degree at the National College of Naturopathic Medicine in Seattle and Emporia, Kansas, [where, by contract, the first 2 years of the 4-year medical education were then taught], or the new North American Naturopathic Institute in North Arlington, New Jersey [there is also a school in Montreal]. The four-year curriculum covers many standard medical courses—anatomy, bacteriology, urology, pathology, physiology, X-ray reading etc.—but also includes botanical medicine, hydrotherapy, electrotherapy, and manipulative technique. The public, by the late 1970s, was particularly ripe for another rejuvenation of naturopathy’s brand of “alternative” health care. As described in Murphy’s Enter the Physician: The Transformation of Domestic Medicine, 1760–1860, when discussing this cyclical rejuvenation in the mid-20th century46: Contemporary crusaders still stress prevention as the layperson’s primary duty, but a growing chorus is calling for every person to assume the newly proactive role in his or her own health care. What would this entail? There are probably as many answers to this question as there are respondents, but it is striking to note how many of the solutions would have been familiar to our ancestors who lived between 1760 and 1860. One recurring idea, for instance, is that each person knows his or her own constitution history the best and therefore has a duty to communicate that knowledge to medical personnel. Another is a refurbished concept of vis medicatrix naturae, the belief that many diseases are self-limiting and therefore do not require much medical intervention—and certainly not the amount or the sort to which contemporary Americans are accustomed. Most significantly, today’s analysts are calling

45

on professionals and nonprofessionals to build and nurture a healthcare partnership very much like that envisioned by 19th-century health publicists: a partnership based on mutual respect, clear understanding, and faithful execution. In that scenario, both as it originally evolved and in its updated version, it is the doctor who directs treatment, but crucial to a successful outcome are the informed and responsible actions of the patients, other caregivers, and the patient’s family and friends. In 1978 the John Bastyr College of Naturopathic Medicine was formed in Seattle, Washington, by Joseph E. Pizzorno, ND (founding president), Lester E. Griffith, ND, and William Mitchell, ND (all graduates of the National College of Naturopathic Medicine), and Sheila Quinn, who felt that it was necessary to have more institutions devoted to naturopathic care and the teaching of naturopathic therapeutics. To differentiate Bastyr from the other “irregular”45 schools, Pizzorno coined the term science-based natural medicine and developed the curriculum to implement it. Bastyr’s cofounder and first president, Joseph Pizzorno, recognized that “anecdotal and unverified ‘cures’, particularly when associated with unusual therapies do our cause little good.” Consequently, instruction at the school “concentrated more on the scientifically verifiable aspects of natural medicine and less on the relatively anecdotal nature cure aspects.”21 In Other Healers, Unorthodox Medicine in America,47 a volume written to provide “a scholarly perspective on unorthodox movements and practices that have arisen in the United States” (from the editor’s preface), author Martin Kauffman, a modern expert in homeopathy from the Department of History at Westfield State College, detailed Bastyr’s homeopathic requirements to graduate: In 1978, three naturopathic practitioners in Seattle founded the John Bastyr College of Naturopathic Medicine. During the sixth quarter all students at that school are required to take 44 hours of course work in homeopathy, after which they may elect another 66 hours and up to 238 hours of clinical homeopathic instruction. The significance of the naturopathic schools to the resurgence of homeopathy is demonstrated by the fact that “about one third of the graduating class specialized in homeopathic practice, a total of about 50 each year in all.”47 During the late 1970s, other naturopathic doctors also recognized the need to establish educational institutions for students of naturopathic medicine; subsequent efforts included colleges in Arizona (the Arizona College of Naturopathic Medicine), Oregon (the American College of Naturopathic Medicine), and California (the Pacific College of Naturopathic Medicine). Unfortunately, none of these three survived. As public demand for natural healing grew in the 1980s and 1990s, the emerging profession continued to grow a breadth and quality of educational opportunity for those seeking accredited doctorate-level programs in naturopathic medicine. With thriving enrollments at Bastyr and National College, the Council on Naturopathic Medicine was founded in 1978 to establish and oversee educational standards, and today it is recognized by the U.S. Secretary of Education as the national accrediting agency for programs leading to the doctor of naturopathic medicine (ND or NMD) or doctor of naturopathy (ND) degree. To further build on the cornerstone of accredited education and ensure educational quality, in 1986 the Naturopathic Physician Licensing Examination became the first national board examination for graduates; today, graduates must pass a two-part medical examination in biomedical and clinical sciences before they are eligible to use the title “ND.” This examination is modeled after the conventional medical board examination for allopathic graduates, the U.S. Medical Licensing Exam, which assigns the “MD” license. This training was described in detail in a report

46

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from 2001 by the University of California San Francisco Center for Health Professions: “Naturopathic physicians are typically trained in a wide array of alternative therapies including herbology, homeopathy, massage, hydrotherapy, physical medicine, behavioral medicine, Traditional Chinese medicine, Ayurvedic medicine, acupuncture, and nutrition therapy, as well as clinical practices such as minor surgery, pharmacology and obstetrics.”48 With educational standards set, throughout the 1990s and 2000s, a select group of new programs and institutions attained accreditation status with the Council on Naturopathic Medicine: Southwest College of Naturopathic Medicine and Health Sciences, Tempe, Arizona; the College of Naturopathic Medicine at the University of Bridgeport, Connecticut; the Canadian College of Naturopathic Medicine, Toronto, Ontario; and, in 2011, the Boucher Institute of Naturopathic Medicine, British Columbia, Canada. The establishment of multiple geographic locations for this type of education paves a solid future for the profession, providing hundreds of newly graduated naturopathic doctors every year in the United States and Canada. There are favorable commentaries on the current state of naturopathic medicine. Other Healers, Unorthodox Medicine in America47 is a volume written to provide “a scholarly perspective on unorthodox movements and practices that have arisen in the United States.” As described in the Encyclopedia of Alternative Health Care by Olsen49: While naturopathic medicine is now legal (in several states), many naturopaths practicing in other states are old-timers, practicing under their original “drugless therapy” licenses, issued before laws prohibiting new naturopathic practices went into effect. In cooperation with regional associations, the AANP has won licensure and scope-of-practice protection at a steady rate on par with the growth of schools accredited by the Association of Accredited Naturopathic Medical Colleges. As of 2011, 15 U.S. states, the District of Columbia, five Canadian provinces, and the U.S. territories of Puerto Rico and the U.S. Virgin Islands regulate the naturopathic profession (Box 3.1). Baer’s interest in the evolution of chiropractic as a philosophy of healing led him to Wardwell’s work and to Wardwell’s earlier scholarship, which had been tied to the mixer orientation within chiropractic. Baer took note of his descriptions of naturopathy as a near-extinct philosophy. Predictions of extinction were consistent among the assessments of social scientists in the 1970s and continued into the mid-1980s. Twaddle and Hessler, Rosengren, Whorton, and most notably, Wardwell all discussed naturopathy as a once-observable but marginalized philosophy of health and healing at odds with the conventional medical claims of a scientific medicine (see Bibliography). These social scientists placed naturopathy’s demise sometime in the 1950s when chiropractic severed its open naturopathic link by terminating ND programs. Baer, before Wardwell, took special note of Bastyr and the professionalization represented by its scientific medicine–based curriculum and the publication of a John Bastyr College of Naturopathic Medicine project, The Textbook of Natural Medicine. In his 1992 Medical Anthropology article43 “The Potential Rejuvena­ tion of American Naturopathy as a Consequence of the Holistic Health Movement,” Baer detailed his own view of Naturopathy’s “three stages of development” noted at the outset of this chapter. Besides relying on material covered in the original chapter of “The History of Naturopathic Medicine,” which first appeared in 1985, Baer covered much of the new material regarding the emerging (1900–1930s) and declining (1940– 1970s) stages of naturopathy. Baer particularly broke new ground with his recognition of a “potential rejuvenation” of naturopathy as naturopathic medicine and

BOX 3.1  States/Districts/Provinces That

Regulate the Naturopathic Profession (updated 2018) States Alaska Arizona California Colorado Connecticut Hawaii Idaho Kansas Maine Massachusetts Minnesota Montana New Hampshire North Dakota Oregon Pennsylvania

Rhode Island Utah Vermont Washington  Districts and Territories District of Columbia Puerto Rico U.S. Virgin Islands  Provinces Alberta British Columbia Manitoba Nova Scotia Ontario Saskatchewan

his recognition that the profession had knowingly or unknowingly adopted a recognized survival strategy as a matter of organizational policy: professionalization. Baer also advanced a theory regarding the “potential rejuvenation” as tied to the emergence in the 1970s of holistic medicine. Holistic medicine, as a philosophy of healing, had a cultural affinity with the eclecticism inherent in naturopathic philosophy. In his 2001 book50 Biomedicine and Alternative Healing Systems in America, Baer updated this view of the status of naturopathic medicine in a chapter entitled “Naturopathy and Acupuncture as Secondary Professionalized Heterodox Medical Systems.” With the passage of the additional 10 years, Baer observed50: Unlike chiropractic, which no longer poses a serious threat to biomedicine because of its status as a specialty emphasizing spinal manipulation, a rejuvenated naturopathy finds itself in direct competition with biomedicine because both systems claim to provide a comprehensive approach to health care. As osteopathy and chiropractic did earlier, naturopathy … [is] increasingly incorporating the theory and social organization of biomedicine. [N]aturopathy with [its] reductionist philosophy and [its] focus on individual responsibility for healthy living may well undergo further growth in an era of growing health costs. 

THE 21ST CENTURY AWAITS Baer carried his examination of the sociopolitical aspects forward in his 2001 article “The Sociopolitical Status of U.S. Naturopathy at the Dawn of the 21st Century,”51 which examined the state of naturopathic medicine as it prepared to enter the 21st century. Although “professionalized naturopathy has undergone tremendous growth and legitimization since the late 1970s, nevertheless, it finds itself in a tenuous situation at the dawn of the twenty-first century in that its strength is confined primarily to the Far West and New England; it faces increasing competition from the partially professionalized and lay naturopaths; and it faces the danger of being overshadowed by a powerful biomedical system that is increasingly incorporating aspects of holistic health into its own practice.”

CHAPTER 3 

The History of Naturopathic Medicine: Origins and Overview

He offered no definitive answers to these questions of naturopathic medicine’s future, but he also highlighted areas needing further attention by social scientists: continued exploration of the reasons for naturopathy’s decline and rejuvenation and continued study of the naturopathic profession in recognition of its state of professionalization. In closing, Baer observed: “In sum, while changes in the popular ideas about health and healing unleashed the social forces that enabled professional naturopathy to get back on its feet, those same social forces may overwhelm its core claim to being a unique, natural approach to healing.” Whorton expressed the view that in many respects the transition from the marginalized naturopathy to the professionalized naturopathic medicine has now been accomplished.52 He traced his view of this transformation as part of the larger transformation “from alternative medicine to complementary medicine” on the part of osteopathy, chiropractic, and naturopathy. Whorton described the factors that allowed this transformation even after the death of Lust in 1945: the issue of the “field’s lack of a scientific basis” was determined internally when the “died-in-the-wool believers in ‘nature cure’” were outlasted by the “liberal practitioners belonging to the so-called western group, naturopaths concentrated in the western states who recognized the validity of mainstream medicine’s scientific foundation and sought to incorporate biomedical science into their own system and apply it under the guidelines of naturopathic philosophy.” As Whorton noted, “a key figure among the pseudomedicals was John Bastyr—a practitioner in Seattle since the 1930s, and particularly wellknown for his advocacy of natural childbirth.” Bastyr, Whorton noted, “recognized the necessity of naturopathy staying abreast of advances in

47

biomedical science and applying those advances ‘in ways consistent with naturopathic principles.’”21 Bastyr was directly involved with the formation and maintenance of the NCNM during the years of naturopathy’s decline and lived to see much of “the short history of John Bastyr College [of Naturopathic Medicine] ... the most compelling illustration of the triumphant rebirth of naturopathy as naturopathic medicine.”21 Bastyr has been called the “father of modern naturopathic medicine” by Pizzorno, ND,52 the moving spirit behind the professionalization of naturopathic medicine and the founding president of Bastyr University. No individual has carried the practice of NDs in the United States in the way that Lust did, but Bastyr and the others profiled by Kirchfeld and Boyle in Nature Doctors kept naturopathy alive during its decline in the 1950s and 1960s so that it could, in time, reemerge. The movement continues to grow, and thus the effect of natural healing has come full circle. In an era where the statistical number of persons born who are expected to contract cancer, now recognized as a degenerative disease, has increased rather than declined and where the incidence of other degenerative diseases (arthritis, arteriosclerosis, atherosclerosis, etc.) has increased in direct relation to the lengthening of life expectancies produced by improved sanitation and nutrition (although speciously claimed by AMA medicine to be the result of their therapies), the early teachings of Lust, Lindlahr, and others appear to have more validity than ever.

REFERENCES See www.expertconsult.com for a complete list of references.

REFERENCES 1. Starr P. Social Transformation of American Medicine. New York: Basic Books; 1983. 2. Griggs B. Green Pharmacy. London: Jill: Norman, & Hobhouse; 1981. 3. Medical Protestants Haller J. The Eclectics in American Medicine. Carbondale, IL: Southern Illinois University Press; 1994. 4. Whorton J. Crusaders for Fitness. Princeton, NJ: Princeton Press; 1982. 5. Rothstein W. American Physicians in the 19th Century. Baltimore: Johns Hopkins Press; 1972. 6. Haller J. American Medicine in Transition, 1850–1910. Urbana, IL: University of Illinois Press; 1981. 7. Rosen G. The Structure of American Medical Practice. Philadelphia: University of Pennsylvania; 1983. 8. Brown ER. Rockefeller Medicine Men. Berkeley, CA: University of California Press; 1978. 9. Campion F. AMA & US Health Policy Since 1940. Chicago: AMA Publishers; 1984. 10. Burrows J. Organized Medicine in the Progressive Era. Baltimore: Johns Hopkins Press; 1977. 11. Coulter H. Divided Legacy. Vol. 2. Washington, DC: Wehawken Books; 1973. 12. Salmon JW. Alternative Medicines. New York: Tavistock; 1984. 13. Gevitz N. The D.O.’s. Baltimore: Johns Hopkins Press; 1982. 14. Silberger J. Mary Baker Eddy. Boston: Little Brown; 1980. 15. Lindlahr H. Philosophy of Natural Therapeutics. Vol. 1. England: Maidstone: Maidstone Osteopathic; 1918. 16. Lust B. Universal Directory of Naturopathy. Butler, NJ: Lust; 1918. 17. Kruger H. Other Healers, Other Cures. A Guide to Alternative Medicine. New York: Bobbs-Merrill; 1974. 18. Kellogg JH. New Dietetics. Battle Creek, MI: Modern Medical Publications; 1923. 19. Ernst R. Weakness Is a Crime: The Life of Bernarr MacFadden. Syracuse, NY: Syracuse University Press; 1991. 20. Whorton J. Inner Hygiene: Constipation & the Pursuit of Health in Modern Society. New York: Oxford University Press; 2000. 21. Whorton J. Nature Cures: The History of Alternative Medicine in America. New York: Oxford University Press; 2002. 22. Wardwell WI. Chiropractic; History and Evolution of a New Practice. St. Louis: Mosby; 1992. 23. Thomas L. The Youngest Science. Boston: Viking; 1983. 24. Reed L. The Healing Cults. Publication No. 16 of the Committee on the Costs of Medical Care. Chicago: University Press; 1932. 25. Wiese G, Ferguson A. How many chiropractic schools? An analysis of institutions that offered the D.C. degree. Chiropract Hist. 1988;8(1): 27–36. 26. “Primary education”—circa 1922—was an eighth-grade education, and this educational base would have been the same as that required by chiropractic. 27. The results of Reed’s work are also summarized in the CCMC’s Publication No. 27, “The Costs of Medical Care” (Falk, Rorem, and Ring [1933], p. 292), as “Naturopaths and Other Drugless Healers.” 28. With lengthy discussion of Central States College of Physiatrics (Eaton, Ohio), the Colorado Mineral Health School (Denver), Columbia College of Naturopathy (Kansas City), First National University of Naturopathy (Newark, New Jersey, earlier the United States School), the Metropolitan College (Cleveland), the Nashville College of Drugless Therapy (Tennessee), the National College of Drugless Physicians (part of the National College of Chiropractic, Chicago), the Polytechnic College and Clinic of Natural Therapeutics (Fort Wayne, Indiana), the Southern University of Naturopathy and Physio-Medicine (Miami), the University of Natural Healing Arts (Denver), and the Western States College (Portland, Oregon). 29. Goulden J. The Best Years. New York: Atheneum; 1976. 30. Caute D. The Great Fear. New York: Simon & Schuster; 1978. 31. The defendant was Otis G. Carroll of Spokane, Washington. He and his brother, Robert V. Carroll, Sr., of Seattle, were longtime associates of Benedict Lust. As members of Lust’s American Naturopathic Association, they had advanced naturopathy’s presence in Washington State through the Washington State Naturopathic Association.

32. Spitler HR. Basic Naturopathy. Des Moines: ANA; 1948. 33. Kuts-Cheraux AW. Naturae Medicina. Des Moines: ANPSA; 1953. 34. Wardwell WI. Comparative factors in the survival of chiropractic: a comparative view. Sociol Symp. 1978;22:6–17. 35. As to those calling themselves naturopaths, this number was considerably too high, as will become apparent. 36. Wardwell WI. Limited and marginal practitioners. In: Freeman H, Levine S, Reeder LG, eds. Handbook of Medical Sociology. Upper Saddle River, NJ: Prentice-Hall; 1979:240–242. 37. Brinker F. The role of botanical medicine in 100 years of American naturopathy. Herbal Gram. 1998;42:49–59. 38. Now the National Bureau of Economic Research. 39. Bureau of Economic and Business Research. Survey of Naturopathic Schools. Salt Lake City: University of Utah; 1958. 40. Homola S. Bonesetting, Chiropractic and Cultism. Panama City, FL: Critique Books; 1963. 41. Cohen W. Naturopathy. In: Independent Practitioners Under Medicare: A Report to Congress. Washington, DC: US Department of Health, Education, and Welfare; 1968. 42. The State Licensing of Health Occupations; U.S. Department of Health, Education, and Welfare; and the National Center for Health Statistics Public Health Service Publication No. 1758 (1967) reported: “Naturopaths are specifically licensed in at least five States and the District of Columbia. The absence of a State from this list does not imply that there are no licensed naturopaths. Illinois, for example, could be covered by the medical practice act. Texas and Virginia provide for naturopaths on examining boards but no information is available on licensing practices. Elsewhere licensing powers have been abolished and no new licenses have been issued; for example, in 1965 naturopathic licenses renewed in California numbered 66 and in Florida, 136.” 43. Baer HA. The potential rejuvenation of American naturopathy as a consequence of the holistic health movement. Med Anthropol Q. 1992;13:369– 383. 44. Cassedy JH. Medicine in America: A Short History. Baltimore: Johns Hopkins University Press; 1991. 45. Duffy J. From Humors to Medical Science: A History of American Medicine. Urbana, IL: University of Illinois Press; 1993:350. 46. Murphy LR. Enter the Physician: The Transformation of Domestic Medicine, 1760–1860. Tuscaloosa: University of Alabama Press; 1991. 47. Kaufmann M. Homeopathy in America. In: Gevitz N, ed. Other Healers: Unorthodox Medicine in America. Baltimore: Johns Hopkins University Press; 1988:99–123. 48. Hough HJ, Dower C, O’Neil EH. Profile of a Profession: Naturopathic Practice. San Francisco: Center for Health Professions; 2001. 49. Olsen KG. The Encyclopedia of Alternative Health Care. New York: Pocket Books; 1989. 50. Baer HA. Biomedicine and Alternative Healing Systems in America. Madison: University of Wisconsin Press; 2001. 51. Baer HA. The sociopolitical status of U.S. naturopathy at the dawn of the 21st century. Med Anthropol. 2001;15(3):329–346. 52. Pizzorno Jr JP, Bastyr J. The father of modern naturopathic medicine. Integr Med. 2004;3:28–29.

GENERAL BIBLIOGRAPHY Baer HA. Organizational rejuvenation of osteopathy. Soc Sci Med. 1981;15A:701–711. Baer HA. A comparative view of a heterodox system: chiropractic in america and britain. Med Anthropol. 1984;8:151–168. Baer HA. The American dominative medical system as a reflection of social values in the larger society. Soc Sci Med. 1989;28:1103–1112. Barrett S, Herbert V. The Vitamin Pushers: How the Health Food Industry Is Selling America a Bill of Goods. New York: Prometheus Books; 1994. Barrett S, Jarvis W. The Health Robbers: A Close Look at Quackery in America. New York: Prometheus Books; 1993. Berlinger H. A System of Medicine: Philanthropic Foundations in the Flexner Era. New York: Tavistock Publishers; 1985.

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47.e2

References

Berman A, Flannery MA. America’s Botanico-Medical Movements: Vox Populi. Oxford, MS: Pharmaceutical Products Press; 2001. Bloomfield RJ. Naturopathy in traditional medicine and health care coverage. In: Bannerman RH, Burton J, Wen-Chieh C, eds. Traditional Medicine and Health Care Coverage. Geneva: World Health Organization; 1983. Breiger G. Medical America in the 19th century. Baltimore: Johns Hopkins Press; 1972. Cody G. History of naturopathic medicine. In: Pizzorno J, Murray M, eds. Textbook of Natural Medicine. Orlando FL: Churchill Livingstone; 1999:17–40. Coward R. The Whole Truth: The Myth of Alternative Health. London: Faber & Faber; 1989. Duffy J. The Healers. Urbana, IL: University of Illinois Press; 1976. Engel J. Doctors and Reformers. Columbia: University of South Carolina Press; 2001. Farrell JB. Naturopathic legislation and education. Rhode Island Med J. 1945;28:248–263. Fishbein M. The Medical Follies. New York: Boni & Liveright; 1925. Fishbein M. The New Medical Follies. New York: Boni & Liveright; 1925. Fishbein M. Quacks and Quackeries of the Healing Cults. Girard, KS: Haldeman-Julius Publications; 1927. Fishbein M. Fads and Quackery in Healing. New York: Covici, Friede Publishers; 1932. Flannery MA. John Uri Lloyd: The Great American Eclectic. Carbondale: Southern Illinois University Press; 1998. Goodenough J. Dr Goodenough’s Home Cures & Herbal Remedies. New York: Crown; 1982. Gort EH, Coburn D. Naturopathy in Canada: changing relationships to medicine, chiropractic and the state, social science and medicine. Soc Sci Med. 1988;26:1061–1072. Green H. Fit for America: Health, Fitness, Sport & American Society. New York: Pantheon Books; 1986. Griggs B. Green Pharmacy. London: Jill, Norman & Hobhouse; 1981. Haller Jr JS. Medical Protestants: The Eclectics in American Medicine, 1825–1939. Carbondale: Southern Illinois University Press; 1994. Haller Jr JS. Kindly Medicine: Physio-Medicalism in America, 1836–1911. Kent, OH: Kent State University Press; 1997. Haller Jr JS. A Profile in Alternative Medicine: The Eclectic Medical College of Cincinnati, 1845–1942. Kent, OH: Kent State University Press; 1999. Inglis B, West R. Alternative Health Guide. New York: Knopf; 1983. International Society of Naturopathic Physicians Yearbook. Los Angeles: ISNP; 1948. Kaufmann M. Homeopathy in America. In: Gevitz N, ed. Other Healers: Unorthodox Medicine in America. Baltimore: Johns Hopkins University Press; 1988. Kirchfeld F, Boyle W. Nature Doctors: Pioneers in Naturopathic Medicine. Buckeye, OH: Buckeye Naturopathic Press; 1994. Ludmerer K. Learning to Heal. New York: Basic Books; 1985. Manger LN. A History of Medicine. New York: Marcel Dekker; 1992. Maretzki TW. The “Kur” in West Germany. Soc Sci Med. 1987;24:12. Maretzki TW, Seidler E. Biomedicine and naturopathic healing in West Germany: a historical and ethnomedical view of a stormy relationship. Cult Med Soc. 1985;9:383–421. McKeown T. The Role of Medicine: Dream, Mirage, or Nemesis?. London: Nuffield Provincial Hospitals Trust; 1976. Mills D. Study of Chiropractors, Osteopaths and Naturopaths in Canada. Ottawa, Canada: Royal Commission on Health Services; 1966. Rogers N. An Alternative Path: The Making and Remaking of Hahnemann Medical College and Hospital of Philadelphia. New Brunswick, NJ: Rutgers University Press; 1998. Rosenberg C. The Care of Strangers: The Rise of America’s Hospital System. New York: Basic Books; 1987. Rosengren WR. Sociology of Medicine: Diversity, Conflict and Change. New York: Harper & Row; 1980. Roth J. Health Purifiers and Their Enemies: A Study of the Natural Health Movement in the United States. New York: Prodist; 1976. Rothstein W. American Physicians in the 19th century. Baltimore: Johns Hopkins Press; 1972.

Serrentino J. How Natural Remedies Work. Vancouver, BC: Hartley & Marks; 1991. Twaddle AC, Hessler RM. A Sociology of Health. New York: Macmillan; 1977. Twaddle AC, Hessler RM. A Sociology of Health. Rev ed. New York: Macmillan; 1987. Utah Legislative Council Staff. A study of the healing arts with particular emphasis upon naturopathy (a report to the legislature). In: Vollmer HM, Mills DL, eds. Professionalization. Upper Saddle River, NJ: Prentice-Hall; 1958. Wardwell WI. Social Strain and Social Adjustment in the Marginal Role of the Chiropractor (PhD dissertation). Boston: Harvard University; 1951. Wardwell WI. A marginal professional role: the chiropractor. Social Forces. 1952;30:339–348. Wardwell WI. The reduction of strain in a marginal social role. Am J Sociol. 1955;61:16–25. Wardwell WI. Orthodox and unorthodox practitioners: changing relationships and the future status of chiropractors. In: Wallis R, Morley P, eds. Marginal Medicine. London: Peter Cohen; 1976. Wardwell WI. The present and future role of the chiropractor. In: Haldemann S, ed. Modern Developments in Chiropractic. New York: Appleton; 1980:25–41. Wardwell WI. Chiropractors: challengers of medical domination. In: Roth J, ed. Research in the Sociology of Health Care. Greenwich, CT: JAI Press; 1982:207–250. Wardwell WI. Chiropractors. In: Gevitz N, ed. Other Healers: Unorthodox Medicine in America. Baltimore: Johns Hopkins University Press; 1988. Whorton JC. Drugless healing in the 1920s: the therapeutic cult of sanipractic. Pharm Hist. 1985;28:14–25. Wirt A. Health & Healing. New York: Houghton Mifflin; 1983. Wohl S. Medical Industrial Complex. New York: Harmony; 1983.

NATUROPATHIC BIBLIOGRAPHY Abbot JK. Essentials of Medical Electricity. Philadelphia: WB Saunders; 1915. Altman N. The Chiropractic Alternative: How the Chiropractic Health Care System Can Help Keep You Well. Los Angeles: JP Tarcher; 1948. Barber ED. Osteopathy Complete. Kansas City: Private; 1896. Baruch S. An Epitome of Hydro-Therapy. Philadelphia: WB Saunders; 1920. Benjamin H. Everybody’s Guide to Nature Cure. 7th ed. London: Thorsons; 1981. Bennet HC. The Electro-Therapeutic Guide. Lima, OH: National College of Electro-therapeutics; 1912. Bilz FE. The Natural Method of Healing. New York: Bilz, International News; 1898. Dejarnette MB. Technic & Practice of Bloodless Surgery. Nebraska City, NE: Private; 1939. Downing CH. Principles & Practice of Osteopathy. Kansas City: Williams; 1923. Filden JH. Impaired Health (Its Cause & Cure). 2nd ed. Denver: Private; 1921. Finkel H. Health via Nature. New York: Barness Printing & Society for Public Health Education; 1925. Foster AL. Foster’s System of Non-Medicinal Therapy. Chicago: National Publishing Association; 1919. Fuller RC. Alternative Medicine and American Religious Life. New York: Oxford University Press; 1989. Goetz EW. Manual of Osteopathy. Cincinnati: Nature’s Cure; 1909. Gottsschalk FB. Practical Electro-Therapeutics. Hammond. Frank Betz; 1904. Graham RL. Hydro-Hygiene. New York: Thompson-Barlow; 1923. Inglis B. Natural Medicine. London: William Collins; 1979. Johnson AC. Principles & Practice of Drugless Therapeutics. Los Angeles: Chiropractic Education Extension Bureau; 1946. Just A. Return to Nature. Lust B, trans. Butler, NJ: Lust Publications; 1922. Kellogg JF. Rational Hydrotherapy. Battle Creek, MI: Modern Medical Publications; 1901:1902. Kellogg JH. New Dietetics. Battle Creek, MI: Modern Medical Publications; 1923. King FX. Rudolf Steiner and Holistic Medicine. York Beach, MA: Nicolas-Hays; 1987.

References Kuhne L. Neo-Naturopathy (New Science of Healing) Lust B, trans. Butler, NJ: Lust Publications; 1918. Lust B. Universal Directory of Naturopathy. Butler, NJ: Lust Publications; 1918. MacFadden B. Power & Beauty of Superb Womanhood. NJ: Physical Culture Publications; 1901. MacFadden B. Building of Vital Power. New York: Physical Culture Publications; 1904. Murray CH. Practice of Osteopathy. Elgin, IL: Private; 1906. Murray MT, Pizzorno JE. Encyclopedia of Natural Medicine. Rocklin: CA: Prima; 1998. Pizzorno JE. Total Wellness. Rocklin, CA: Prima; 1996.

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Richter JT. Nature—The Healer. Los Angeles: Private; 1949. Spitler HR. Basic Naturopathy. Des Moines: ANA; 1948. Trall RT. Hydropathic Encyclopedia. Vols. 1–3. New York: SR Wells; 1880. Turner RN. Naturopathic Medicine: Treating the Whole Person. London: Thorsons; 1984. Weltmer E. Practice of Suggestive Therapeutics. Nevada, MO: Weltmer Institute; 1913.

4 The History of Naturopathic Medicine

A New and Revisionist Perspective: The Lost Years of the 20th Century George W. Cody, JD, MA

OUTLINE Introduction and Author’s Note, 48 Part One: Who were the Naturopaths?, 49 In the Beginning, 49 Germ Theory and Conventional Medicine, 49 The Early Integrators, 49 The Early 20th Century, 51 Drugless Healing, 51 Benedict Lust, 51 Naturopathy and Chiropractic, 51 Nature Cure and the Vital Force, 52 Genesis of Post–WWI Professionalism, 52 A Short Course in Medical Dominance, 52 A Time to Build a Profession: The 1930s, 53 Dr. Budden and Evolution of the Profession in the Pacific ­Northwest, 53 Robert V. Carroll, ND—Leader of NDs in Washington, 54 Natural Healing at its Peak, 55 A Profession, 56 The Merging of Efforts, 56 Firming Up the Curriculum—Chiropractic and Naturopathy, 57 New Developments in Postwar Scholarship, 57 A.R. Hedges, DC, ND, and W. Martin Bleything, DC, ND—First Connections, 58 The AMA and President Truman, 60 Enter the Class of 1953, 60 More Professional Matters for Dr. Budden, 61 Part Two: What Happened to Them?, 62 Moving On, 62

Headwinds, 62 Revisiting Basic Science, 63 And Scandals, 63 And Repercussions, 64 More Basic Science, 64 Dr. Schlichting, 65 Back to the National Scene, 66 Dr. Schlichting Becomes President, 66 Naturopaths at Their Peak, 67 The Late 1940s and Professional Growth, 67 In Memoriam—Robert V. Carroll, Sr., 67 1947–1950 and Forward, 67 After the Scandals, 68 A Change of Identity, 68 Medical Dominance Arises, 68 The Beginning of the End, 69 The Texas Medical Wars, 69 Back to Education: WSC and Natura Medicina, 69 Back to Texas, 71  The End, 73 The End, Part 2, 74 And Naturopathy Is Finished at WSC, 74 Back to the Texas Medical Wars, 75 Three More States Fall: 1955 to 1957, 76 The Florida Saga Begins, 77 Utah, 78 Washington State Under Siege, 78 A Dismal State of Affairs: The 1960s, 79

INTRODUCTION AND AUTHOR’S NOTE

healing between 1945 and 1975 that this chapter will seek to explore and document—a history that is surprisingly rich and deep. Discovering and documenting the history of this period had to wait until resources became available for research. Five new resources that became available in the past 10 to 15 years are at the heart of this new chapter. All of these resources have become available—accessible for research—due to modern technology. The first is the library resources of the modern naturopathic colleges, primarily Bastyr University and what is today the National University of Natural Medicine (NUNM). These resources, though, have largely not been digitized and required old-fashioned “shoe leather” research.

When earlier chapters on natural healing in the United States were researched and written, the available sources were primarily the extensive publications of Benedict Lust and the works of other historians. When other historians had looked extensively at naturopathy—historians such as James Whorton, Hans Baer, or (recently) Susan Cayleff— they also relied on primarily on Benedict Lust. This has left a historical gap between Lust’s death in 1945 and the 1970s when a modern naturopathic medicine emerged and began making its own historical record. But there is a hidden history of natural

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CHAPTER 4  This work is greatly indebted to the “shoe leather” of Eric Blake, ND, of Portland, Oregon (and to Mitchell Stargrove, ND, also of the Portland area, who introduced this author to Eric’s work). Eric had spent many hours about 15 years ago researching the stacks of material in the NUNM “rare book” room with an eye to what Benedict Lust either did not tell us or any off-track items that were buried in Lust’s publications. This led to many hours of conversation and correspondence between this author and Eric that led down the path of a new historical synthesis. Second, the John Bastyr archives at Bastyr University then opened up material that Dr. Bastyr had saved from this era that had been in boxes, unexplored. Chief among these was a collection (not complete) of the publications of the Western American Naturopathic Association (ANA)/American Naturopathic Physicians and Surgeons Association/ American Association of Naturopathic Physicians from 1947 to 1954. Dr. Bastyr was a protégé of Dr. Robert V. Carroll Sr., who had brought Bastyr into the world and practice of naturopathy, as these records documented. (Thanks are owed to the staff of the library at Bastyr University, especially Jane Saxton and Linda Tally.) Third is the archive materials at the W.A. Budden Library of the University of Western States (UWS) in Portland, Oregon. The UWS is the modern successor to Dr. Budden’s Western States College where Dr. Budden was president from 1929 to 1954. What was not already digitized and accessible on the UWS website was scanned and made available to this author by the archive librarian, Katie Lockwood. She also deserves a large credit for advancing this historical work product. Fourth is two resources on the history of the UWS and of chiropractic: the history of the UWS by Lester Lamm, DC, and the history of chiropractic education by Keating, Rehm, and Callender, which includes the detailed minutes of the Council on Education of National Chiropractic Association, within which Dr. Budden participated, operated, and influenced.1 Fifth, and finally, a massive amount of newspaper archive material has been digitized and made available. Coupled with search-engine capacities, a completely buried panorama of natural healing history has gone through a supernova process. Armed with these voluminous materials, the questions “Who were the naturopaths?” and “What happened to them?” can at last start to be answered. Editors’ Note: This is the second of two chapters documenting the origins and evolution of naturopathic medicine. Although these were written to stand alone, a full understanding requires reading both chapters. 

PART ONE: WHO WERE THE NATUROPATHS? Natural healing advanced a science-based alternative to the American medical profession of the 20th century; this alternative philosophy started first as naturopathy as promulgated by Benedict Lust, and then its concepts and practice evolved into naturopathic medicine primarily through the work of three early pioneers: Henry Lindlahr, William C. Schulze, and Walter B. Cannon, all medical doctors disenchanted by conventional medicine moving in what they considered the wrong direction. By the early 1950s, natural healing—an alternative to conventional medicine practiced by chiropractors and naturopaths—reached its peak. Practitioners were spread across the United States, and their common philosophy was based on a belief in the vital force—the inherent healing power within all of us. The leadership of W.A. Budden and Robert V. Carroll was critical to the professional growth of natural healing from the mid-1930s to the early 1950s. They led a professionalization movement within natural healing that brought these practitioners to the peak that was reached in the post-WWII United States. 

IN THE BEGINNING In the early 20th century there was medicine as practiced by medical doctors (“MDs”) and as represented in the United States by the American

The History of Naturopathic Medicine

49

Medical Association (AMA). The AMA became, over the first 75 years of the 20th century, one of the most powerful political interest groups in US history and became known as “organized medicine.”2 There were alternatives that emerged early in the 20th century, primarily in the form of chiropractic, naturopathy, and other “drugless’ schools of healing as well as in the work of MDs who diverged from the AMA’s concept of “scientific medicine.” Scientific medicine was based on Louis Pasteur’s “germ theory.”

Germ Theory and Conventional Medicine At the turn of the 20th century, as Howard Berliner (1985) has documented, straight germ theory (germ x causes disease y) became established as the core concept of “scientific medicine” in American allopathic medical education. At the time, the major rivalry in American medicine was between allopaths (about 60% of medical practitioners) and homeopaths (about 30%, the balance being Eclectics and physio-medicalists). Once the substantial resources of the Rockefeller philanthropies were put behind scientific medical education based on germ theory— with the full consent of the AMA—American medicine became synonymous with the germ theory. This, the Flexner Report (1910), and medical research devoted to finding pharmaceuticals to defeat germs to “cure” disease were all funded by Rockefeller philanthropies and led to what is considered to be the dominant paradigm in American medicine.3 As Berliner documents, this was largely the result of a determination to put the Rockefeller philanthropic resources behind this concept of “scientific medicine” not, at the time, any clear clinical superiority on the part of the allopathic philosophy. As of the period in which this took place, largely 1900 to 1920, there was no clinical validation for scientific medicine in terms of the discovery of specific pharmaceuticals of demonstrated efficacy.

Be’champ, Bernard, and the Alternatives to Germ Theory The concept of an alternative to the germ theory of disease traces to two French contemporaries of Louis Pasteur: Augustine Be’champ and Claude Bernard. Pasteur’s work asserting microbes as the cause of disease has been well documented and lauded and does not need to be reproduced here. Be’champ’s theory was, put as simply as possible in the biological sense, that “germs” are always present in our environment and do not “cause” disease. Disease is related, rather, to the physiology of the host, the human (or mammalian) body, not to the germs per se. What we observe in microbiology relative to disease is the resultant by-product of the body’s failed attempt to reject a pathogenic microbe, a function that a healthy body’s autoimmune system should accomplish.4 Bernard’s work in physiology was much celebrated in the 19th century. As noted by Charles Gross (1998): “Today the fame of Claude Bernard rests primarily (if not entirely) on his idea that the maintenance of the stability of the internal environment (milieu interieur) is a prerequisite for the development of a complex nervous system.” But as noted by Gross and others, although Bernard advanced this idea between 1854 and his death in 1874, it “had no impact for over 50 years after its formulation.” Why did this “insight that the ‘constancy of the internal environment is the condition for the free life’ (have) no significance (indeed no meaning) for biologists for more than 50 years?” One major reason was that “Pasteur’s new bacteriology and its omnipresent, omnipotent germs, were dominating the biomedical Zeitgeist.”5 

The Early Integrators In the pre-WWII years, the work of three MDs that diverged from germ-theory orthodoxy became central to the emergence of integrative medicine. These three MDs are Henry Lindlahr, William Charles Schulze, and Walter B. Cannon.

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SECTION 1 

Philosophy of Natural Medicine

Henry Lindlahr and Integration in Clinical Practice The standard biography of Lindlahr is that of Kirchfeld and Boyle in Nature Doctors.6 His own therapeutic philosophy is set out in his four-volume work Natural Therapeutics, published in 1923 and republished in 1975 as edited by Jocelyn Proby, DO.7 The four volumes are Philosophy, Practice, Dietetics, and Iridiagnosis. Lindlahr started his own school in Chicago in 1914 and built a substantial sanitarium, clinic, and college operation as well.8 A central tenet of Lindlahr’s work, in spite of his medical training, was that the allopathic approach to healing was wrong. There were, he said, “two principal methods of treating disease. One is the combative, the other the preventive… The slogan of modern medical science is, ‘Kill the germ and cure the disease’… The combative method fights disease with disease, poison with poison, and germs with germs.”9 On the other hand, “The preventive method does not wait until disease is fully developed and gained ascendancy in the body, but concentrates its best endeavors on preventing, by hygienic living and natural methods of treatment, the development of disease.”10 In Philosophy, he states: “It is the intent of this volume to warn against the exploitation of destructive combative methods to the neglect of preventive constructive and conservative methods. If these teachings contribute something toward this end they will have fulfilled their mission.” His work is consistent with Walter Cannon’s physiological insights, and a decade before Cannon’s Wisdom of the Body was published, he wrote in Philosophy: The diet expert, the hydrotherapist, the physical culturist, the adjuster of the spine, the mental healer and the Christian Scientist, pay little attention to the pathological conditions or the symptoms of disease. Each of these, in accordance with his theory of disease and cure, regulates the diet and habits of living on a natural basis, promotes elimination, teaches correct breathing and wholesome exercise, corrects the mechanical lesions of the body, or establishes the right mental and emotional attitude, and, in so far as he succeeds in doing this, builds health and so diminishes the possibility of disease. The successful doctor of the future will have to fall in line with the procession and do more teaching than prescribing.11 Lindlahr strongly advocated for Be’champ’s theories, especially in his Philosophy volume. He had discovered Be’champ’s work, he said, through the earliest work of Ethel Douglas Hume.12 Specifically, Lindlahr noted that he had then “made a careful study of [Be’champ’s] last work, entitled The Blood, in which he summarizes the mycrozymian theory of cell life.” From this study, Lindlahr found “a rational, scientific explanation of the origin, growth and life activities of germs and of the normal living cells of vegetable, animal and human bodies.”13 At two points in Philosophy, Lindlahr discusses at length the understanding of Be’champ’s work that he has gained from his own intense study of Be’champ’s writings and how from his own clinical observations and experience, and from Be’champ’s work, he comes to advance three primary manifestations of disease. These manifestations of disease are (1) lowered vitality (vitality is the body’s strength of positive resistance and recuperative power, the “vital force” of cellular function); (2) abnormal composition of blood and lymph; and (3) accumulation of waste, morbid matter, and poisons in the system.14 

William Charles Schulze and Integration in Medical Education Schulze was an MD (of Rush Medical College) who, in 1914, purchased the National School of Chiropractic and broadened its curriculum to include the basic sciences as well as “physiological therapeutics” and mechano-therapy.15 The name was changed in 1920 to the National College of Chiropractic (NCC). His most enduring influence may have come from acquiring and merging Lindlahr’s school after Lindlahr’s untimely passing in 1924 and in his mentoring influences on W.A. (Alfred) Budden, DC,

ND, of Portland’s Western States College and, later on, Joseph Janse, DC, ND, the postwar president of National College (1945–1983).16 As Keating and Rehm noted about Schulze: Part of the Schulze legacy is the tradition of broad-scope, “rational chiropractic,” or what Palmer called “mixing.” As an MD, Schulze had been trained in medical and presumably some minor surgical procedures, but he had apparently committed himself to “drugless healing” early in his career. However, drugless healing, which involved a variety of naturopathic methods, was anathema to the Palmer branch of the profession. The physician-chiropractor would quickly run afoul of the adiagnostic, nontherapeutic, subluxation-only forces in the profession.17 Schulze sought “to promote a professionalism among students and doctors which could rival that of medical competitors,” and under Schulze, the NCC introduced laboratory courses in pathology, biochemistry, bacteriology, and toxicology, together with a “strong commitment to diagnostic training,” all in response to the adoption in the late 1920s of the Basic Science Law. The NCC adopted the motto “four ways to beat the basic science law”: (1) Study basic science. (2) Study basic science. (3) Study basic science. (4) Study basic science. Schulze came under much criticism from the “straights” in chiropractic, and this only increased after he purchased the Lindlahr School of Natural Therapeutics from Henry Lindlahr’s estate and transferred “the entire student body and the better part of the faculty” to the NCC.18 In 1928 this part of the National school was formed into the National College of Drugless Physicians, which was National’s ND degree program. The National College of Chiropractic Journal became a voice that extended beyond the NCC itself by the early 1920s, becoming a professional voice as well, challenging B.J. Palmer’s “straight” chiropractic philosophy as well as the antagonism of Morris Fishbein, MD, the editor of the Journal of the American Medical Association (JAMA). This voice was first found under the NCC secretary, A.J. Forster, MD, DC, and then “under the editorship of William Alfred Budden, DC, ND, an English immigrant and former economics instructor at the University of Alberta who graduated from the NCC in 1923.”19 From the mid-1920s, Schulze was involved more in the professional activities than in the day-to-day operations of the NCC, and always in the “mixer” camp—first in the American Chiropractic Association (ACA) and then starting in 1930 in the successor National Chiropractic (NCA). Schulze then followed a busy, nationwide speaking schedule in the early 1930s, advocating consistently for the broad-scope professional values of the NCA as taught at the NCC/NCDP. At the 1934 annual meeting of the NCA (May 1934), Schulze—a regular speaker at these annual meetings—noted in his speech that at the time, “harmony among Chiropractors and Drugless practitioners, especially the Naturopaths, was good to look upon.”20 In 1934 Dr. Schulze joined a convention tour coined “the Northwest Circuit” organized by C.O. Watkins, DC, of Montana that had its speakers speak at NCA-affiliated conventions held in Minnesota, North Dakota, Montana, Washington, British Columbia, Idaho, Utah, Wyoming, and Colorado. The Washington stop was for the meeting of the Northwest Chiropractors Association and was a gathering of 300 attendees from Oregon, Washington, Idaho, Northern California, and British Columbia in September.21 The last full year that Dr. Schulze was actively engaged was 1934; he was in ill health for much of 1935 and passed away in September 1936. When he passed away, one of the very many appreciation letters honoring his productive life was sent by Dr. Robert Carrol as the president of the Washington State Naturopathic Association, saying, “The entire drugless profession has lost a friend and teacher.”22 In 2002 Rehm and Keating noted as Dr. Schulze’s great accomplishment, “Schulze created an intellectual environment that would be

CHAPTER 4  rivalled in the middle age of the profession only at Budden’s Western States College.”23 

Walter B. Cannon and Integration in Medical Research Cannon did extensive research in physiology, his area of teaching at Harvard. He concurred with Bernard’s concept of the “internal environment” of the human body and coined the term homeostasis to describe the body’s need to respond physiologically to the external environment to maintain a stable internal environment, which he described as a primary function of the central nervous system.24 His concept was that through what he called the “wisdom of the body,” mammalian forms such as the human body “may be confronted by dangerous conditions in the outer world and by equally dangerous possibilities within the body, and yet continue to live and carry their functions with relatively little disturbance,” something that Hippocrates had called vis medicatrix naturae. In a distinctive passage in The Wisdom of the Body, Cannon set forth a concept that became central to the postwar chiropractor-naturopaths: The fathers of medicine made use of an expression, “the healing forces of nature,” the vis medicatrix naturae. It indicates, of course, recognition of the fact that processes of repair after injury, and of restoration to health after disease, go on quite independent of any treatment that the physician may give … In the first place, the well-trained physician is acquainted with the possibilities and limitations of self-regulation and self-repair in the body. He is instructed in that knowledge and employs it not only for his own intelligent action but also as a means of encouragement for the patient who looks to him for counsel … Again, the physician realizes better than the layman that many of the remarkable capacities of the organism for self-adjustment require time—all of the processes of repair belong in that class—and that they can play an important role in restoring the organism to efficiency only if they are given the chance that time provides … Furthermore the physician realizes that he has at his command therapeutic with which he can support or replace the physiological self-righting or self-protective processes we have been considering … Finally a great service which the physician renders is the bringing of hope and good cheer to his patients. He has seen at work in many cases the restorative processes of the organism … When we are afflicted and our bodily resources seem low, we should think of these powers of protection and healing which are ready to work for the bodily welfare.25 Lindlahr was the greatest direct influence on the post-WWII philosophy of natural therapeutics, the central core of “drugless” or “nonmedical” philosophy. Lindlahr’s and Cannon’s work have a remarkable consistency between them, although Lindlahr was largely influenced by Be’champ and Cannon by Bernard. Together they advanced the work of these two 19th-century French scientists into the 20th century, and in doing so, they advanced a scientific basis for an “alternative” to the germ theory that was at the core of conventional “scientific medicine.” Schulze pioneered the education of physicians in a professional “drugless” therapeutics consistent with the theoretical work of Lindlahr and Cannon. 

THE EARLY 20TH CENTURY The shaping of America’s modern healthcare landscape began in what historians call the Progressive Era—roughly 1900 through the end of World War II in 1919. At the turn of the 20th century, the AMA had begun the elevation of allopaths over homeopaths and Eclectic

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physicians—all MDs—and had completed this process by the end of the Progressive Era, aided by the 1910 Flexner Report and the efforts of the Rockefeller and Carnegie Foundations (see previous discussion). By the early 1920s, what had become the AMA’s monopoly structure within the medical profession was in place.26

Drugless Healing But as homeopaths and eclectics disappeared, a wide range of practitioners known as “drugless healers” emerged. In this period the licensing structure that became a critical part of the AMA’s monopoly structure had not been fully adopted across the United States, and these drugless healers, probably several thousand of them, were to be found in practice. The practitioners of manipulation modalities— including osteopaths and chiropractors, but others as well, such as mechanotherapists and naprapaths—were “drugless.” So were myriad others, including practitioners of neuropathy, physcultopathy (physical culture), sanipractic, food science, suggestive therapeutics, and Swedish movement. Some of these drugless healing practitioners were specifically regional; naprapaths were almost exclusively found in Illinois, where D.J. Palmer protégé Simon Oakley had founded his school, and sanipractors were originally exclusive to the state of Washington before advancing their presence into British Columbia in Canada.27 

Benedict Lust In 1902 Lust originated his use of the term naturopathy and began his development of a theory and philosophy of health and healing “to describe the eclectic compilation of doctrines of natural healing that he envisioned was to be the future of natural medicine.” Lust launched his career as the progenitor of naturopathy, adopting that name for his eclectic brand of natural therapeutics and placing the term naturopath firmly in the title of his monthly publications, which continued under his status as editor and publisher until his death in 1945.28 One of the anomalies of Lust’s work was that for at least 30 years, there was no firm definition of naturopathy; rather, Lust clearly attempted to incorporate all methods of “drugless healing” and “natural therapeutics” into his philosophy of naturopathy. This included the original concept of osteopathy devised by Dr. Still and chiropractic as devised by D.D. Palmer. In Lust’s view, these were all pieces of naturopathy, linked together by not being “allopathic medicine.”29 This “drugless” label could only incorporate Still’s osteopathy in its original form, which did not incorporate a materia medica, as described, for instance, in Charles Hazzard’s Principles of Osteopathy (3rd edition, 1899).30 Where chiropractic was concerned, Lust’s naturopathy became clearly allied with the “mixer” philosophy, and both Lust and the mixers were in conflict at the time with the “straights” led by B.J. Palmer.31 

Naturopathy and Chiropractic Precisely when chiropractic and naturopathy first became melded into a symbiotic relationship is historically murky. D.D. Palmer did not—at least as historically reported—practice or teach naturopathy or openly associate himself with it. His son, B.J., was adamantly opposed to anything that would dilute the purity of “straight” chiropractic. Benedict Lust, the historical progenitor of naturopathy in America, taught and endorsed chiropractic very early in the 20th century, but it was Solon Langworthy, an early student of D.D.’s, who opened the second identifiable school of chiropractic in 1903 and based its curriculum on mixing nature cure with chiropractic. Palmer was the originator of chiropractic, of course, but he adopted a kind of “Johnny Appleseed” approach to his spinal manipulation insights, “planting” the concept of chiropractic adjustment more than

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anything else. He was traveling constantly after 1902 and granting the right to practice and to educate others in his methods to recipients of his written “diplomas.” It was B.J. Palmer, the son, who adopted a proprietary interest in chiropractic after his graduation from D.D.’s instruction in 1902, much as Lust did in naturopathy. Both chiropractic and naturopathy could best be described as social movements in the field of health and healing in their first two decades of evolution. It was not until the 1920s that others began to work at the professionalization of chiropractic and naturopathy, and many of the most influential of these who became connected with naturopathy were chiropractic “mixers,” becoming known in time as the chiropractor-naturopaths or “DC, NDs.” 

Nature Cure and the Vital Force Benedict Lust’s vision of drugless healing, although it continued to “expand,” as noted by Susan Cayleff, was always intended to be consistent with Germanic 19th-century “nature cure.” As noted by Henry Lindlahr is his 1915 book Nature Cure, the original concepts were credited to Vincent Preissnitz.32 As noted by Lindlahr, nature cure became “the idea of drugless healing [which] spread over Germany and over the civilized world.”33 Citing Lindlahr, Susan Cayleff summarized American nature cure’s idea of human sickness this way: Henry Lindlahr, MD, a leader in naturopathic philosophy, explained the five specific conditions that caused disease; lowered vitality; abnormal composition of blood and lymph, resulting mainly from wrong eating and drinking; accumulation of waste, producing morbid matter and poison in one’s system; mechanical lesions, that is pressure, tension or strain on nerves and nerve centers caused by luxations (dislocations) of bony structures or straining of muscles and ligaments; and discordant or destructive mental and emotional attitude. These conditions more or less remained the core of naturopathy for decades.34 Treatment by means of nature cure theory relied on the body’s own drive to maintain health—to achieve what Walter Cannon later called “homeostasis”—by recognition of what was labeled the “vital force.” The work of F.E. Bilz, a German MD, was very influential in this regard. Bilz first published his synthesis of German nature cure in Germany in 1898, and in 1901 he published Natural Method of Healing: A Complete Guide to Health (translated from the latest German edition) as the English language version of his work.35 Bilz noted: “[I]t is known that we cannot heal a disease with the remedy we apply, but that it is the vital force within us which heals, and that we need but aid it, [and] our position becomes a far easier one.”36 This “vital power,” the “power of healing,” Bilz said, “resides in man himself … divine nature placed it there at the creation of each being.’’ Adopting this concept, Lindlahr noted that all healing must “economize vital force” because it is the vital force that “is the Supreme power and intelligence, acting in and through every atom, molecule and cell in the human body which is the true healer, the vis medicatrix nature which always endeavors to repair, to heal and to restore …”37 

GENESIS OF POST–WWI PROFESSIONALISM To understand the DC, NDs and their professionalization requires going beyond the career of Benedict Lust and the natural living and healing movement that he founded. It also requires more historical background. The committed professionalization process that followed began in the late 1920s and continued through the first years after WWII. The focus was on moving the educational process and the clinical

practice of both naturopathy and chiropractic past the “founder’s grip” of Benedict Lust and B.J. Palmer by means of the creation of stable residential colleges and stable state and national professional organizations. This task was compounded with regard to both of these professions by the committed drive by organized medicine in the United States (primarily in the form of the AMA and its state and local constituencies) toward medical dominance. To respond to the determination of medicine to achieve this dominance, a resistance based on the core values of “Americanism” was required, along with personal resilience and tenacity.

A Short Course in Medical Dominance Medical dominance is best understood by reference to the book of this same name by Australian sociologist Evan Willis.38 The subject can be supplemented by a very useful work by another sociologist, Saul Rosenthal, A Sociology of Chiropractic.39 These sociologists argue that organized medicine has had as a goal since at least 1900 the achievement of medical dominance in domains: achievement of complete control over its own work (autonomy), achievement of complete control over the work of others in health care (dominion), and achievement of complete control over all matters of public policy within the health domain (medical sovereignty). Willis’s argument is sophisticated and extensive; indeed, his discussion of the subject is a book-length treatise. But the short version as it relates to the “exclusion” of “alternative” practices like chiropractic and naturopathy can be summarized. Relying on earlier work by Howard Berliner and others, he demonstrates that medicine’s dominance was achieved through the allopathic claiming of the mantle of “science” for its work. This was done through the adoption of the germ theory of disease.40 This, in turn, had two advantages, as Willis argues: first, individual clinical skill became less important than extensive schooling within a laboratory and hospital-based system (“clinical skill” versus “clinical science”), and second, health became an individual scientific problem, not a social, environmental or lifestyle problem.

The “Great Trade” In the United States, this manifested itself in the early 20th century as “the Great Trade” described by Fredric Wolinsky: “[B]y 1925, the AMA had gained a monopoly over the production and licensing of physicians. This included the power to determine what the curriculum should be, how many students should be admitted, which students should be admitted, and how many faculty there should be for each student. Thus 1910 marked a trade of importance between society (as represented by state and federal governments) and the AMA. The trade gave the AMA the exclusive right and sole power to regulate the medical profession. In return, the AMA was to give society the best and most efficient medical care system possible. Society has clearly lived up to its part of the bargain …”41 

American Exceptionalism “American exceptionalism” or “Americanism” has been analyzed extensively in the book of the same name by Professor Seymour Martin Lipset, one of the most distinguished US academicians. Professor Lipset gives this synopsis of Americanism: “The American Creed can be described in five terms: liberty, egalitarianism, individualism, populism and laissez-faire.”42 Medical dominance strikes at each of these five values, all in the name of “scientific medicine.” It is based on using the power of the state to enforce the “great trade” as public policy, the antithesis of populism. It is corporatist, not individualist and laissez-faire. It creates a

CHAPTER 4  favored class of medical professionals over serving egalitarianism, and by the exercise of the power of the state, it constrains the liberty of the patient as a consumer. 

A Time to Build a Profession: The 1930s The drugless healing concepts of nature cure became, by the 1930s, the philosophical basis for a professional alternative to conventional medicine in the form of the chiropractor-naturopaths, the “DC, NDs.” By the mid-1930s, as Susan Cayleff notes, Benedict Lust came to abandon “therapeutic inclusivity” and declared that a clear and fixed professional identity was necessary.43 For some others who had already formed a professional identity and founded schools and colleges, this moment of self-reckoning came not a moment too soon. It was time to bring all of this into focus as a professional identity once and for all.

The Move Toward Professionalization By the 1930s, the concept of “drugless healing” began to change, and significantly. The majority within osteopathy was moving to add materia medica to osteopathic manipulation and prescribing in line with allopathic thinking and the germ theory.44 The majority within chiropractic were “mixers,” perhaps 70% of chiropractors.45 And within naturopathy, the amalgamation period of the previous 30 years was giving way to identification as naturopaths and abandonment of other drugless labels.46 In the case of osteopathy, the conflict between the originalists and the modernists played out within the American Osteopathic Association (AOA) in the form of battles over “standards” applicable to the osteopathic colleges. Among chiropractors, two professional associations emerged by the early 1930s, the National Chiropractic Association (NCA), which was the association for the “mixers” within chiropractic, and the B.J. Palmer–led Chiropractic Health Bureau, which in 1941 became the International Chiropractic Association—the organization of the “straights.” From the AMA’s perspective, the “straights” were the most easily labeled as a “healing cult.” The straights stood politically for 18-month schooling directed toward identifying “subluxations” of the spine and resolution by manual spinal adjustment as the treatment for all human ailments. A high school education was considered sufficient as a prerequisite for a “straight” chiropractic education. The NCA had adopted a 4-year residency education requirement by the end of the 1930s, led by the Metropolitan Chiropractic College, Western States College (WSC or Western States) and the National Chiropractic College. A leader in consistently upgrading educational standards within the NCA was W.A. Budden of Western States. Within naturopathy, the transition in the 1930s was more complex. As pointed out by Susan Cayleff, by 1935 Benedict Lust moved away from considering all drugless healers part of naturopathy, regardless of how they identified themselves. After three decades, he instead declared that all naturopaths needed to identify as such, encouraging all remaining drugless healers to openly join the naturopathic movement.47 Kirchfeld and Boyle assert that Lust had gone beyond the establishment and popularization of the American naturopathic movement by the end of the 1920s and “must be credited with four other accomplishments.” These were founding the American School of Naturopathy, founding the ANA, his publications, and “the legal status of naturopathy attained as a result of his efforts,” which they call “the most tangible of his efforts.” They note that “it is difficult to separate the success of Lust’s organizations from that of his publications.”48 By the early 1930s, the success of Lust’s efforts must be deemed “qualified.” A 1927 survey by a committee of the AMA of all “schools of chiropractic and naturopathy” found Lust’s combined American School

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of Chiropractic and American School of Naturopathy to be a night school program operating classes for 3 hours each weeknight for a 4-year, 9-months-per-year course. No catalog was published due to expense, but the school was described in Lust’s monthly publications. The school as of 1927 and forward was not established to function in the era of the Basic Science Law, and moreover, neither chiropractic nor naturopathy was licensed in New York. In 1935 Lust was found guilty of illegally (under New York law) issuing diplomas awarding a “doctor” degree without a lawful state charter. It is true that Lust’s ongoing influence was from his publications and from his continued popularization of naturopathy through his travels and his speeches. Through this popularization, others were able to obtain legal status for naturopaths in several states, but this was largely accomplished by others in the movement. Lust’s own operations were in New York (school and publications), New Jersey (his first Yungborn Sanitarium) and Florida (second Yungborn Sanitarium). Of these states, only Florida granted naturopaths recognized legal status, and this was accomplished by others in the movement. By the 1930s, an alternate vision formed within the ANS and within some of the NCA schools that offered ND degrees in addition to DC degrees. As Lust’s influence declined during WWII and after his passing in 1945, others came forward with a competing vision of the relationship between chiropractic and naturopathy, of naturopathic education, and of nonmedical clinical practice. How this came about is a piece of history that has not been well documented before. The story centers on a few men and women, the most prominent of whom are W.A. (Alfred) Budden of Western States College, with its Schools of Chiropractic and Naturopathy, and Robert V. Carroll of the ANA. 

Dr. Budden and Evolution of the Profession in the Pacific Northwest Budden’s Early Career and Arrival in Oregon

W.A. Budden, DC, ND, educated at Schulze’s National College and later a Pacific Northwest (NW) transplant, was a leader in the professional development movement of drugless physicians. Over time, Budden acquired several staunch allies in this effort. The alliance of DCs and NDs in the Pacific NW began through the efforts of Dr. Budden and took root during the remarkable Oregon ballot campaign of 1934. This alliance continued to grow in the aftermath of the ballot fight, as Dr. Budden lived by what he considered to be the lessons of this formative campaign. This ballot campaign of 1934 was Dr. Budden’s brainchild. Budden himself had come west from Chicago to Portland, Oregon, steeped in a “mixer’s” amalgam of core chiropractic, physiotherapy, and Lindlahr’s natural therapeutics. Budden attended Schulze’s National College from 1922 to 1924. Upon graduation as a DC, he joined the faculty and in 1925 succeeded the college’s previous dean and school journal editor.49 It was at this time that National purchased and absorbed Lindlahr’s College of Natural Therapeutics, the premier drugless school of the time. Budden was integrally involved in the integration of the Lindlahr programs into national as the college’s ND degree program. As an educator and administrator at National through the 1920s, Budden also authored a textbook for use at National: Physiotherapy: Technique and Treatment.50 In 1929 Budden moved to Portland, and his career as an educator began in earnest. When Budden arrived in Portland in 1928, he purchased the Pacific Chiropractic College for cash; in 1933 the Pacific College was reincorporated and renamed the Western States College. Western States’ core mission was “for the purpose of operating a college that would offer

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DC and ND degrees together with training nurses and health technicians and maintain clinics and hospitals.”51 When he arrived, Budden also networked with both Oregon’s chiropractors and naturopaths. Chiropractic had been licensed first in Oregon in 1915; licensure for naturopathy was more recently established, in 1927.52 He spoke at the Oregon Chiropractic Association’s 22nd Annual Meeting in July of 1929, and then in July of 1930, he spoke at the annual meetings of both the Oregon Chiropractic Association and the Oregon Naturopathic Association. These speaking appearances became a tradition carried out many times with each group over the years until his death in 1954.53 Oregon adopted a Basic Science Law in 1933.54 Dr. Budden’s initial view was that the Basic Science Law was the medical profession’s creation intended specifically to blunt the rise of any competition to MDs, specifically that of DOs, DCs, and NDs. But Budden’s first effort was to try to craft a political response to a political problem. As Budden later related the history of this effort, “October, 1933, saw the formulation of a joint legislative committee to manage the drafting of and the campaign for an amendment to the constitution of Oregon regulating the practice of the healing arts.” The Joint Legislative Committee (JLC) was the joint committee of the Oregon Association of Chiropractic Physicians and the Oregon Naturopathic Association, and as Dr. Budden described, it was “composed of an equal number of chiropractors and naturopaths.”55 The first action of the JLC was to work with legal counsel to draft what became known as the “Healing Arts Amendment,” a proposed amendment to the Oregon Constitution by citizen’s initiative.56 As the news report in The Oregonian, Portland’s and Oregon’s largest newspaper, reported, “petitions for this measure contained approximately 47,000 signatures against the 26,667 required by law. The completed petitions were brought to Salem [Oregon’s capital] by a caravan of 14 automobiles.”57 On Election Day, after an exhaustive 6-month effort, the ballot measure went down by a 3-to-1 margin. This attempt to curtail medical dominance in Oregon was, on the surface, not successful. Nonetheless, Dr. Budden, over time, took heart from what he considered to be the “lessons learned” from the campaign.58 Moreover, he gained some considerable respect for his willingness to engage in politics and the tenacity with which he could wage a political campaign even with limited resources, and this would be to his advantage over the years.59 These were lessons that he seemed to take to heart and that animated him for the next 20 years of his career as an educator and a consummate professional. From these “lessons learned,” Dr. Budden committed himself to several things. He accepted the basic sciences as a necessary part of a “nonmedical” physician’s education, although he continued to argue that professional examinations were best given to candidates by each profession’s licensing board. He actually, in time, came to view the Oregon examinations as quite fairly conducted, and his students gained a high passing rate as the curriculum focused on these subjects as part of the core education in both chiropractic and naturopathy.60 He continued an extensive public-speaking schedule, regularly appearing through the 1930s, the war years, and in the postwar era before lay audiences like the HEL and the Biochemistry League as well as holding speaking events at Western States and giving weekly radio talks. He continued at all times to commit his WSC programs to provide a sound and thorough education to his students in both the School of Chiropractic and the School of Naturopathy. He worked

tirelessly to improve the standards for all similar colleges and took the lead at every turn in increasing the coursework and prerequisites required.61 These alliances and friendships were important to the WSC and to professional development in the Pacific NW. Dr. Budden, and his DC, ND allies, built stability into the education and organization of chiropractic and naturopathy, especially in the western United States and the Pacific NW, but much of their work is forgotten today. One of these alliances will be discussed here as part of Dr. Budden’s efforts to secure strength and stability for both chiropractic and naturopathy in the Pacific NW and at WSC: that with Robert Carroll, DO, ND, of Seattle. 

Robert V. Carroll, ND—Leader of NDs in Washington One of the strongest leaders and professional organizers in his own right was Robert V. Carroll Sr., DO, ND. Dr. Carroll had built the naturopathic profession in Washington. Licensing in Washington was granted under the Drugless Healing Act of 1919. Licenses were actually issued for the practice of sanipractic, a drugless school unique to Washington.62 But Carroll, although his license said “Sanipractic,” was determined to build a distinct identity professionally and allied early with Benedict Lust’s ANA.63 Robert V. Carroll (Sr.) was also educated in Chicago after WW I, graduating from the American College of Osteopathy and the Lindlahr College of Natural Therapeutics (both Lindlahr schools) in 1923. Carroll finished his studies with Lindlahr and his school faculties just a year before Lindlahr’s sudden death from an infection in late March of 1924. Lindlahr’s signature is on Carroll’s Doctor of Natural Therapeutics diploma,64 and Carroll spoke often in later years of having been a student of Lindlahr himself. Carroll moved west to Washington right after graduation, stopping for a year to practice with his brother, O.G., in Spokane before moving on to Seattle.65 By 1930 he had begun the process of professional organization in Washington, founding the Washington Association of Drugless Physicians and serving as its president for 8 years, with the organization’s name changing to the Washington State Naturopathic Association in 1934.66

The Beginning of the Budden–Carroll Alliance The complete origin of Carroll’s association with Dr. Budden and his support for Western States is unclear. Both Drs. Carroll and Budden studied in Chicago at about the same time. Dr. Budden made an alliance with the DCs and NDs in Oregon in the early 1930s and as a leader in the drugless professions in Washington. Dr. Carroll had his own connections with the Oregon NDs. Yet still, any connection that they had before the 1934 Ballot Campaign is not yet documented. But in the immediate aftermath of the campaign, they joined forces, as reported by Benedict Lust. In February 1935, the same month that the Chiropractic Journal published Dr. Budden’s “Medical Propaganda” article detailing B.J. Palmer’s efforts to defeat the Oregon Ballot Campaign, Lust used his “Dr. Lust Speaking” platform in the Naturopath and Herald of Health67 to similarly interfere in professional efforts in the Pacific Northwest (subtitled “Schisms”): Word has come to us of a meeting that was called for Portland, Ore., in December last for the purpose of the “unification and coordination of Naturopathy and Chiropractic.” This went out on the letterhead of the Washington Naturopathic Association with headquarters in Seattle and was signed by the president, Dr. Robert V. Carroll.

CHAPTER 4  Another letter from the Western States College of Portland signed by Dr. A. Budden, calls for a meeting to be held in Seattle on January 12th to put the “finishing touches” on an organization to be known as the International non-Medical Alliance. Let us say right here and now that we are against any alliance between Naturopaths and Chiropractors. (Naturopath and Herald of Health, February 1935, p. 34) Lust went on to say that alliances with the chiropractors in California and elsewhere had helped chiropractors and hurt naturopaths and that furthermore, there should only be the ANA to speak for naturopaths and no other associations or groups that purport to represent naturopaths. “We have no fault to find with Dr. Carroll or Dr. Budden. We are however utterly opposed to the formation of other organizations that would usurp the prerogatives and program of the A.N.A. This organization has stood the test of time.” 

NATURAL HEALING AT ITS PEAK In March 1952 Henry J. Schlichting Jr., ND, appeared before the 42nd annual convention of the Oregon Association of Naturopathic Physicians in Portland, Oregon. At the time, Schlichting was the president of the American Naturopathic Physicians and Surgeons Association (ANPSA).68 Schlichting was quoted as saying that two major national issues facing naturopaths were that alternative schools got no tax support and that naturopaths could not be admitted to tax-supported hospitals. This created “a heavy demand on our profession and the lay public to meet rising … costs.” Schlichting was reported to have told the convention, “Despite these problems the profession ‘is making definite progress on a national scale as evidenced by licensing in over 20 states,’ [and] insurance companies are recognizing naturopaths ‘because they are getting satisfactory results.’”69 Although the “licensing in over 20 states” was a generous count, there was no question that at the time Schlichting was speaking, the natural healing alternative was at its peak. Schlichting was from Midlands, Texas, a West Texas city where all major oil companies had a presence in a state where there were almost 500 licensed naturopaths.70 Specific licensing of naturopathy was in place in 8 states (out of 48); 2 states had naturopaths practicing under drugless licensing, and about a dozen other states had broad, “mixer” licensing of chiropractors. In other states, naturopaths were fairly openly practicing without licensing but consistently pursuing legislation. Natural healers were practicing in about 40 of the 48 states.71

What Is the Vital Force? What bound this natural healing profession together was a belief in the vital force and a resistance to “suppressive drugs,” those pharmaceuticals that relieved symptoms without treating the underlying disease state. Between the mid-1930s and the early 1950s—separate from Benedict Lust and his publications—this doctrine of the vital force became central to natural healing in a manner most consistent with Walter Cannon’s concept of homeostasis: Yet, we must ever keep in mind that there is no disease to be cured; there are only sick people to be healed… The physician must support the inherent nature of the patient by whatever means…By supporting the inherent power—the vital force—we re-establish a harmonious functioning of the disordered parts or functions.

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It is not the physician that cures, but the indwelling vital force that heals. Since it is the vital force that heals, we must seek those methods and do for the patient those things which will best support the natural healing powers of the particular person; we must be careful to do nothing that would interfere with that healing force. If we are not to interfere with the workings of the vital force in its attempt to heal, then we must carry on our practice in conformity with … the laws of nature. The mere use of a naturopathic method or modality does not mean you are practicing Naturopathy in conformity with its principles and philosophy. If such methods are used as a suppressive treatment, the physician is practicing Allopathic and not Naturopathic medicine. As naturopathic physicians we must work … in accordance with natural law. (“Editorial” by A.R. Hedges, DC, ND,72 Journal of the ANA, May 1950) 

Credit to Budden and Carroll The leadership of W. A. Budden and Robert V. Carroll was critical to the professional growth of natural healing from the mid-1930s to the early 1950s. Their alliance had begun formally in late 1934.73 From 1935 forward, Budden was the trailblazer in natural healing education. Robert Carroll became a trailblazer in the professional organization of natural healers, and through a network of common associates, they each supported the work of the other. Budden accepted the basic sciences as a necessary part of a “nonmedical” physician’s education, although he continued to argue that professional examinations were best given to candidates by each profession’s licensing board. He actually, in time, came to view the Oregon examinations as quite fairly conducted, and his students gained a high passing rate as the curriculum focused on these subjects as part of the core education in both chiropractic and naturopathy.74 

Education He continued at all times to commit his WSC programs to provide a sound and thorough education to his students in both the School of Chiropractic and the School of Naturopathy. He worked tirelessly to improve the standards for all similar colleges and took the lead at every turn in increasing the coursework and prerequisites required.75 But it must be understood that Dr. Budden considered chiropractic and naturopathy as complementary, as part of a complete package, and his friends and allies were like-minded; they were “DC, NDs.” Emblematic of this view are two events that took place in the mid-1930s: WSC joined in the school alliance known as the “Affiliated Universities of Natural Healing,” and Dr. Budden recommitted Western States to a broad natural healing, drugless, progressive curriculum. The first of these, the affiliation, was the brainchild of Homer G. Beatty, DC, ND, the president of the University of the Natural Healing Arts (UNHA) in Denver, Colorado. The four schools that were advertised in 1935 as being “affiliated” were Western States and the UNHA, joined by the Metropolitan College of Chiropractic and Physiotherapy of Cleveland, Ohio, and the University of the Healing Arts of Hartford, Connecticut. These schools were affiliated in recognizing that the goal of “a regular standard, four years of nine months each, course in Chiropractic and allied subjects is warranted by our profession and offered by the … school members of this affiliation.”76

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The commitment to curriculum was significant, and WSC was a leader in this area, especially in naturopathy. Western States was, as of 1933, located at 538 S.E. Alder Street, Portland, and remained at this location until late 1939. The WSC Schedule of Classes and Hours, first printed in May 1933 and in use throughout the college’s stay at the S.E. Alder location, set out a curriculum for both the chiropractic and naturopathy programs of 4000 hours of total study over 4 school years, each consisting of 8 months of residential attendance. The school year was September through July of the following year.77 The programs had 2750 hours of common study, starting with the basic sciences, and then “upper-class” requirements of 1250 hours specific to each program. Both courses of study had coursework in physiotherapy, electrotherapy, and hydrotherapy, with the major differences between the programs being the chiropractic coursework in clinical neurology versus the naturopathy coursework in herbology and biochemistry. In actual practice, students enrolled in the chiropractic program and then added the naturopathy program as provided for in the schedule: “After receiving either the D.C. degree or the N.D. degree, the other degree may be secured by an additional 4 months’ work; both degrees cannot be awarded within the regular course.” The graduating class of July 1937 was typical, with seven DC graduates, four of whom also received the ND degree.78 And Dr. Budden was firm in his commitment to a broad natural healing education and a corresponding view of the DC and ND professions. In 1935 he wrote to the Chiropractic Journal to object to the idea that “coagulation of tonsils and dehydration of hemorrhoids” were construed as surgery and therefore not defensible as part of chiropractic. He said, “Western States College stands foursquare behind the members of the profession who are engaged in the practice of electrotherapy as a part of chiropractic.”79 As the Schedule of Classes and Hours noted, under Oregon law, chiropractic was “that system of adjusting with the hand or hands the articulation of the bony framework of the human body, and the employment and practice of physiotherapy, electrotherapy and hydrotherapy.” As Dr. Budden’s letter went on to say: “There is no reason to back down or retreat from the position we have already established.” And he did not, either in the classroom, in clinical practice, or in any public forum. And finally, he made friendships and alliances deeply within both the chiropractic and naturopathic professions of his day. His chiropractic contributions and their effects on the DC profession have been written about elsewhere, but his naturopathic contributions and their effects have not been written about, and so some attention to his efforts in naturopathic education and professionalism will be paid here. He is known as a great chiropractic educator, one of the classic “schoolmen,” but he is also remembered “as a great naturopath.”80 

A Profession When Benedict Lust criticized the alliance formed by Budden and Carroll in late 1934, he was well aware of the Oregon Ballot Campaign and how hard the DC, ND alliance had fought in that 1934 effort. To emphasize the “push” that was necessary in that fight, Budden had addressed the 1934 Oregon Naturopathic Association annual meeting in June on the fight ahead. And through A.R. Hedges, DC, ND, and others in the ND community (which may have included Washington’s Carroll) and to boost interest, the ONA had Lust come out from New York for the meeting.81 Carroll, by all accounts of the events of the next 15 years of activities within the naturopathic profession, was frustrated by Lust’s interference in the political situation in the Pacific NW. What Lust had said struck at the very philosophy of the WSC with its School of Chiropractic and School of Naturopathy. Over the next 15 years, Carroll did three

things: he wrested control of the ANA out of the hands of Lust, the “president for life,” he made it a much more professional organization, and he backed Dr. Budden and Western States at every turn in the process.82 At the 1935 ANA convention in San Diego, Carroll pushed through a new constitution and supporting bylaws modeled on those perfected by the AMA. The state associations would have House of Delegates members based on the membership size of each state. The Board of Directors and Officers would be elected annually, and the Board would conduct much of the business of the ANA, primarily through its Executive Committee. Lust was elected again as president, but the “president-for-life” status was effectively rescinded.83 From this point forward, there were more voices within the ANA. Gradually, Robert Carroll took control of the reins of the naturopathic profession. The final split from the personal grip of Benedict Lust occurred in 1942. The annual convention of the ANA was scheduled for June 1942 in Chicago. The news of this location for the annual meeting had been released at the 1941 annual convention in St. Louis and continually publicized since November of that year.84 By the spring of 1942, Lust came to realize that he was to be challenged for the presidency of the ANA by a group led by Carroll that was seeking a more committed professional development within naturopathy. This group was largely from states that had licensing laws of some kind in place for naturopaths.85 As these naturopaths met in Chicago and elected Frederick Dugdale of Portland, Maine, as their president, Lust and his close associates, Jesse Mercer Gehman of New Jersey and T.M. (Teresa) Schippell of Washington, D.C., hurriedly convened their own meeting in Atlantic City, New Jersey. This meeting of about 70 naturopaths from the eastern United States, almost entirely from unlicensed states, was declared the convention of “the real ANA.”86 Even though Lust would contest the validity of what he called the “pseudogroup” of “pseudo Naturopaths,” until he passed away in the late summer of 1945—and his eastern followers would continue this even longer—it is clear that Dr. Carroll and the Western group acted within the full authority of the constitution and bylaws of the association and were in the “right” in this dispute. In any event, as Schippell wrote at the time, the western “insurgents” led by Robert Carroll had been working to “attract many outstanding naturopaths to their ranks, (and bring) in many state organizations to their membership” and had many “well-known practitioners.”87 Carroll assumed the presidency of the western ANA at the July 1946 convention and held the office for 3 years, until July 1949. 

The Merging of Efforts Carroll was a friend of Western States as president of the ANA and afterward as the group’s past president. In many ways, Western States came to have a favored status among schools that were connected with the teaching of naturopathy where Dr. Carroll and the western ANA were concerned. As the western ANA grew in stature, it began to make three goals clear: to unify all naturopaths in one professional organization (which meant unity with the smaller eastern group left after the death of Benedict Lust in 1945), to advance the goal of a naturopathic profession based in licensed states, and to develop its own clear educational standards. Unity was supposed to take place at the strong and successful Salt Lake City convention in July 1948, during Carroll’s presidency. It did not. But professionalism was much advanced by the creation of a strong committee and organizational structure that Carroll ushered in and by the enlistment of quality professionals like Alton C. Johnson, DC, ND, of California—the author of Principles and Practice of Drugless Therapeutics—into the western ANA membership.

CHAPTER 4  And the ANA adopted Budden’s model of a 4-year, 36-month residence course of study as its educational standard, passing a resolution at its July 1949 convention in Houston, Texas, against recognizing any school that (1) offered any of its instruction by correspondence; (2) offered diplomas rather than a course of instruction; (3) offered to grant multiple degrees for the same course of instruction; (4) granted any advanced standing or transfer credit that was based on study at schools not recognized by the ANA, the American Osteopathic Association, or the National Chiropractic Association.88 This was done as some of the last business conducted under Carroll’s presidency. In December 1949, the Journal of the American Naturopathic Association first published its list of approved schools, listing three schools that would require basic science credits from an outside institution of higher education and Western States as the only school offering residency education in all 4 years of the required curriculum. Moreover, Carroll strengthened the connections between the Oregon DC, ND community and Western States with the western ANA. Carroll personally quelled unrest among some of the ND community and Western States in the postwar years. He visited a regular meeting of the Oregon Naturopathic Association in December 1947 while ANA president, together with his successor as president of the Washington State Naturopathic Association (Dr. Helena Winters of Kelso, Washington). He then made another visit to the ONA monthly meeting a year later in December 1948. As reported in Oregon Pioneer, unrest began in the fall of 1948 within the ND community around Western States that the school was becoming known more as a chiropractic school, or a school of “chiropractic and drugless physicians,” outside of the college. Carroll made the purpose of his 1948 visit as ANA president to express his support for Dr. Budden and Western States as Budden saw fit to operate the college.89 After leaving the presidency in July 1949, Carroll remained active— somewhat more behind the scenes—in matters of the ANA and the Pacific Northwest. The largest issue for the Western ANA for 1950 was the unfinished business of unification with the remaining naturopaths in the eastern group, and for the year between the annual conventions of 1949 and 1950, this was almost all-consuming. Additionally, legal issues arose in Washington State in 1950 regarding the 1919 Drugless Healing Act under which the naturopaths in that state were licensed. These legal issues threatened to do severe damage to the profession’s legal status.90 Unification under the Western group’s national structure was achieved in St. Louis in 1950, although the amalgamation remained messy until the very end. Then, Dr. Robert V. Carroll, a true giant within the naturopathic profession and a friend of Western States College until the end, passed away suddenly in April 1951.91 

Firming Up the Curriculum—Chiropractic and Naturopathy From the time that Dr. Budden opened the “new” or “converted” Western States College in 1934, the curricula in both the School of Chiropractic and the School of Naturopathy showed his imprint.92 The primary philosophy-of-practice texts were Joy Loban’s Technic and Practice of Chiropractic, a text authored in 1915 by a leading faculty member from the National College program, and in naturopathy, Otto Juettner’s A Treatise on Medical Practice (the Art and Science of Non-Medical Therapeutic Methods), a text by a leading Eclectic and physio-medical practitioner. Juettner’s work was first published in 1916 and republished by Benedict Lust’s New York publishing house.93

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The other practice texts in use for the 1930s were Goldthwaite’s Body Mechanics and Marlin’s Manipulative Treatment for nonspinal adjustive technique, Grieve’s Modern Herbal for knowledge of herbal remedies, Luke’s Manual of Natural Therapy for hydrotherapy, Kovac’s Electrotherapy and Light Therapy for electrotherapy, Sherman’s Chemistry of Food and Nutrition for dietetics, and Boyd’s Preventive Medicine for hygiene and public health. The eclectic nature of these texts shows Budden’s wide knowledge of the subject areas included in the Western States curricula, but the use of Loban and Juettner’s works also reflects the fact that although the professions had grown significantly since WWI, the available scholarship had not. This began to change at the end of the 1930s with the publication in 1939 of Homer G. Beatty’s (of the University of the Natural Healing Arts in Denver) Anatomical Adjustive Technique and Alton Johnson’s first edition of The Principles and Practice of Drugless Therapeutics. Also published in 1939 by the National College of Chiropractic was Chiropractic Principles and Technic by Biron, Wells, and Houser of the NCC faculty; this was the first real advancement of the work begun at NCC by Joy Loban in the much earlier days of the profession. And in the late 1930s, John Robinson Verner’s The Logic and Science of Chiropractic first appeared. However, the onset of WWII not only slowed the progress of the colleges, but also the rationing of all materials, including paper, made the widespread use of these new works of scholarship problematic. For 1940 to 1941, the 1938 to 1939 WSC catalog simply had the additional date “1940 & 1941” stamped on the cover; no new catalog appears to have been printed until 1944, and no changes were made to the curricula for the duration of wartime.94 The 1944 catalog, which was used through 1947, included as new texts added to the curricula those by Beatty (added in anatomical adjustment); Biron, Wells, and Houser (added in palpation); and Johnson (1st edition; added in electrotherapy).95 Also, Rational Bacteriology by chiropractic scholars Verner and Weiant was added to the more standard text by Zimmer in bacteriology. 

New Developments in Postwar Scholarship It was not until the fall term of 1947 that new scholarship began to appear in use at an accelerated pace at Western States. The Logic and Science of Chiropractic by Verner (3rd edition, 1946) was added to the curriculum in chiropractic; in naturopathy, Thomas Lake, DC, ND’s Treatment by Neuropathy and the Encyclopedia of Physical and Manual Therapeutics was added. This latter work was a lengthy treatise published in 1946 on what was more generally known as mechanotherapy by a chiropractor-naturopath of some substantial reputation based in southeastern Washington State.96

Dr. Budden on Chiropractic and Naturopathy The first postwar catalog published was entitled “Bulletin of the Western States College, Announcement of the School of Chiropractic and School of Naturopathy.” The college symbol was now a hand holding a torch with the peroration fiat lux, or “let there be light.” For this first postwar catalog, Dr. Budden penned his own descriptions of chiropractic and naturopathy, both as to Pacific NW history and as to philosophy. This material became a constant in WSC’s postwar catalogs into the mid-1950s.97 Prospective students and interested parties were given this introduction to the WSC School of Chiropractic: School of Chiropractic, Founded 1908. The history of Chiropractic is largely the history of its schools. This is particularly true in the Northwest, where the energy and vision of the founder brought forth the D.D. Palmer School of Chiropractic in Portland, Oregon.

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As early as 1908 Dr. Palmer, together with Dr. LaValley, opened the doors of this pioneer institution. Since that day Portland has been the seat of Chiropractic learning in the Northwest. Always an institute devoted to this purpose has stood in the Rose City. The Western States College is therefore the lineal descendant and beneficiary of all that has gone before. It is carrying on the work of the founder as he would have desired it, in this modern manner. Chiropractic literature also found its birthplace in Oregon. The original text, “The Chiropractic Adjuster,” by D.D. Palmer, was published in Portland.” This was the introduction to the School of Naturopathy: School of Naturopathy, Founded 1930 The Latins spoke of it as the Vis Medicatrix Naturae—a remedial force or impulse. The Germans called it Natur Heiling, the remedial impulse of Nature, the self-recuperative power of the bodily system, independent of medicine. It has been described, also, as the capability of living tissue, animal or vegetable, to remedy and remove disease, or to repair the healing power of nature. United in man with the dynamics of the mind, this matchless force constitutes the basis of naturopathic therapy. To intelligently enlist it in the fight against disease is the whole art of non-medical healing. These two short pieces, authored by Dr. Budden, contain his synopses of chiropractic and naturopathy and present the central core of his nonmedical philosophy. 

More Curriculum and Postwar Scholarship By the fall term of 1949, as the Western States Class of 1953 was entering school, the full flowering of postwar scholarship in both chiropractic and naturopathy was available, and Dr. Budden took advantage of the newest works in crafting his curriculum for each program. Through the course of the college terms from fall 1949 to spring 1953 when the class of 1953 was in attendance at WSC, the chiropractic and naturopathy students were educated in two additional new works of nonmedical scholarship: Janse et al., Chiropractic Principles and Technic, 2nd edition, and H. Riley Spitler’s newly published Basic Naturopathy. This latter text was commissioned and published by Carroll’s western ANA with the intention of providing a definitive text in naturopathy. The scholarship is thorough and sound, and it holds up well today as “cutting-edge” work in its time.98 Budden paired Spitler’s text with a classic from the Eclectic–physio-medical school of medical philosophy, Clymer’s Nature’s Healing Agents: The Medicines of Nature (2nd edition, 1926) based on an adaptation of the Thomsonian System. This combination of Verner, Janse, Spitler, and Clymer plus the coursework in dietetics, physical fitness, body mechanics, electrotherapy, physiotherapy, and hydrotherapy demonstrated the clear imprint of Schulze and Lindlahr on Budden’s conception of the nonmedical physician.99 It cannot be overstated that Budden’s students were the broadscope chiropractors and naturopaths of the postwar era. The WSC students Budden produced kept these professions alive, especially in the Northwest, for the next 30 years, into the mid-1970s. This postwar era was the zenith of the period when WSC was the pacesetting educational and scholarship beacon in chiropractic and naturopathy. This postwar period was the WSC era when WSC was the intellectual environment that would be rivaled in the middle age of the professions perhaps only at National College.100 

A.R. Hedges, DC, ND, and W. Martin Bleything, DC, ND— First Connections Another of the friends and allies Dr. Budden first grew close to professionally during the 1930s was A.R. Hedges, DC, ND, of Medford, Oregon. Medford is a smaller city about 275 miles due south of Portland, located just north of the Oregon–California state line. In 1930 when Portland’s population was just over 30,000, Medford’s population was just over 11,000, and the “greater Medford” population (within a 5-mile radius of the city center) was just under 17,000.101 A.R. Hedges had been practicing as a drugless physician in Medford since 1911. His advertisements for his practice with his wife Louisa for their “chiropractic-naturopathic” offices had appeared in the Medford Mail-Tribune as early as 1913.102 Both A.R. and Louisa appeared in Benedict Lust’s Universal Encyclopedia Directory and Buyer’s Guide— Year Book of Drugless Therapy for 1918–1919 as active drugless healers in Oregon. Whether by coincidence or not, Dr. Hedges did not appear on the statewide Oregon scene as a leader in either chiropractic or naturopathy until 1929, just as Dr. Budden was arriving on the scene as well. From here on, the professional arc of these two DC, NDs intersected continually. At the June 1929 annual meeting of the Oregon Chiropractic Association (OCA), the forerunner of the OACP, Hedges was named by the OCA president to the convention’s resolutions committee. This is the first time he appears in any news coverage of OCA affairs. It was at this conference that Dr. Budden gave his first of many addresses to the Oregon profession. Although it is not clear that the two first met each other at this meeting, Dr. Budden drove down to Medford in March 1930 for a Saturday evening meeting of the Southern Oregon Branch of the OCA held at Dr. Hedges’s home in Medford. The Southern Oregon Branch was the professional business section for the southwestern region of the state between annual meetings of the OCA.103 Budden was in the company of the OCA’s president and the secretary of the state Board of Examiners, both doctors from Portland. Plans were being made for the next annual meeting, which was to be held in Medford for the first time. The upcoming legislative session and legislative planning were also discussed.104 Dr. Budden would attend meetings of the Southern Oregon Branch many more times over the years. By the next summer, Hedges was named to his first 3-year term on the Oregon Board of Naturopathic Examiners, serving from 1930 to 1933. Over the course of the 1930s, Dr. Budden and Dr. Hedges crossed paths many times during the professional activities of both the OCA/OACP (the progressive “mixer” group of the state) and the naturopaths of Oregon. This was particularly true during the 1934 Ballot Campaign, in which Dr. Hedges actively participated.105 It would be during the war and postwar years that the association of Drs. Budden, Carroll, and Hedges would have its greatest import for Western States College. But before moving the story forward into the war years, it is necessary to introduce W. Martin Bleything.

Dr. Wallace Martin Bleything Dr. Wallace Martin Bleything first appeared on the Oregon scene in 1937 when he was on the speaker’s roster for the 1937 annual meeting of the Oregon Association of Chiropractic Physicians, the successor to the Oregon Chiropractic Association. This was a meeting held at WSC that also featured Dr. Carroll as a speaker, and the 1937 WSC commencement was held in conjunction with this event.

CHAPTER 4  The subject of Bleything’s speech on this occasion is not known from the news clip available, but at the time, Bleything was working for a research laboratory in Los Angeles. In 1941, just before the United States entered WWII, Bleything appeared as a speaker before an osteopathic postgraduate meeting in Amarillo, Texas, giving a series of talks on endocrinology, a subject for which he was listed as a “nationally-known expert.”106 Just after war broke out, he was awarded his Master of Chiropractic degree from the California Chiropractic College of Oakland, California.107 

Hedges and Bleything—the War and After As America went to war, Hedges’s professional profile continued to rise as a physician who had been in practice for 30 years. In July 1942 he was elected vice president of the Oregon Association of Chiropractic Physicians, and in December of that year he was named once again to the Oregon Board of Naturopathic Examiners to finish a term (through July 1, 1943) for a member of the Board who had passed away.108 In July 1944 he was elected the OACP president at the annual meeting, and he served as president until July 1946. The vice president elected with him in 1944 was another DC, ND, J. W. Sargent, who had worked with Hedges and Budden going back to the 1934 Ballot Campaign if not longer.109 In fact, there was clearly considerable overlap in the 1930s and 1940s between the OACP and the Oregon Naturopathic Association. In 1946 as his successor as OACP president was being elected, Hedges was reappointed to a full 3-year term on the Oregon Board of Naturopathic Examiners.110 In 1949 at the July convention of the ANA in Houston, Hedges was elected second vice president (VP), taking office as Carroll stepped down as president. By November 1949, his hometown Medford newspaper was reporting on his travels across the country in his national position.111 Hedges was now positioned to protect the interests of WSC with the national ANA as well as Carroll, and he continued to do so. Hedges served as second VP of the western ANA for 1 year until July 1950; then, as part of the newly unified ANA, he was elected first VP and twice reelected, serving as first VP from 1950 to 1953. At the 1951 annual meeting, the association had gone through a name change to the American Naturopathic Physicians and Surgeons Association. Hedges wrote the editorial in what was now the Journal of the ANPSA explaining the long story behind the earlier schism, unification, and the reason for the name change.112 He also wrote a series of editorials in the association journal eloquently explaining the difference in core philosophy between the allopaths on one hand and naturopaths and chiropractors on the other; the difference between viewing the physical organism as operating in “conformity with the laws of chemistry” versus the view that the body “is in a vital realm, presided over by a vital force” that maintains life; and the difference between treating symptoms with suppressive means versus “supporting the vital force” to “regain harmonious function” and “to do nothing that would interfere with that healing force.”113 In July 1953 he was elected president, and he was reelected July 1954, serving until mid-1955. This was all capped off for Dr. Hedges when he appeared before the Oregon Naturopathic Association annual meeting in March 1954 as national president.114 Throughout these years, Hedges succeeded Carroll in guarding the interests of the Western States program at both the state and national levels. In 1947 the Los Angeles College of Chiropractic dropped its ND degree program. In 1949 the Metropolitan College of Chiropractic closed. Then in 1950, Homer Beatty of Denver’s University of the Natural Healing Arts suddenly passed away, and the National College of Chiropractic

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dropped its ND degree program. Through these events, the other legitimate, 4-year residency programs were lost. As the largest and strongest organization of naturopaths, the ANPSA had a vested interest in the existence and success of WSC. That brings matters back to Dr. Budden and WSC as the war ended in 1945. Dr. Wallace Martin Bleything, known most often as W. Martin Bleything or Martin Bleything, appears to have been linked primarily to Western States in the postwar era. As the war came to a close, Western States was hanging together but uneasily, as already described. With peace came the wave of returning veterans and a postwar boom of interest fueled by the Servicemen’s Readjustment Act of 1944, or the “G.I. Bill.” About 2.2 million returning veterans used their G.I. Bill benefits to attend colleges or universities, the classification attained by Western States through the Veteran’s Administration, which certified institutions of higher education.115 As Lester Lamm described the circumstances of Western States in Oregon Pioneer: The shortage of students produced by the Great Depression and made worse by World War II disappeared almost overnight, leaving the college with a completely new challenge: what to do with more applicants than the institution could manage. The G.I. Bill filled college and university classrooms across the nation, and the Western States College was the fortunate beneficiary of escalating applications and enrollment numbers. The explosion of growth was unanticipated and the college was not prepared for the magnitude of the student influx it experienced. The makeup of the student population was also challenging. Students demanded the administration provide them with a higher quality education, in a more appropriate facility.116 The school resolved the facilities space problem in late 1946 by purchasing a building on S. E. Alder in Portland, a former lodge building. As A.E. Homewood described it, “this was far from ideal, or a place of beauty, but did offer the necessary space for expansion.”117 Qualified faculty was another matter. The size of the new student population surpassed the method of Dr. Budden doing a lot of instruction supplemented by local practitioners. Enter, among others, Dr. Bleything. Bleything had a varied and colorful background, but most relevant to Western States, he had grown up in Portland, then moved to Seattle shortly before World War I. Interrupted by service during the first war, he had studied chemistry and then worked and studied at Grace University Hospital, a homeopathic and drugless physician training program combined with a sanitarium maternity ward run largely by a homeopathic, fully licensed MD. John Bastyr, DC, ND, after whom Bastyr University is named, had interned there, and Dr. Robert Carroll had been on the sanitarium staff, both during the 1930s. Between 1932 and 1942, Bleything had worked at a research laboratory in Los Angeles as a colloidal chemist, as well as graduating from chiropractic college.118 Bleything arrived at WSC in 1947 and joined the faculty in firstand second-year basic sciences and in third- and fourth-year practice courses in chiropractic. He got licensed in Oregon as a DC and became a member of the OACP. Within another year, he got licensed as an ND and joined the ONA. By 1951 he had been recruited by A.R. Hedges to take over as editor of the Journal of the American Naturopathic Association and had become the lead faculty member in instruction in the naturopathy program at Western States (while still continuing with the basic sciences). Again, Western States had connections deep into the national affairs of naturopathy and was the example naturopaths always turned to when the education of NDs was challenged.119 

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The Western State College Class of 1953

Universal health care—a totally government-funded healthcare system—was a pronounced political goal of President Harry Truman. The political and public relations machinery of the AMA was almost entirely directed at this “threat” to the “American Way” for all of President Truman’s postwar term in office. While organized medicine was politically preoccupied, chiropractic and naturopathy were able to advance. President Truman left office in January 1953, and by the summer of 1953, the AMA was starting a national campaign to eliminate chiropractors and naturopaths as competitors, but until then, battles were fought on a state-by-state basis.121 As previously discussed, the National Chiropractic Association (NCA)—the chiropractic “mixer” group—was directing its accredited colleges to shut down any of their nonchiropractic degree programs, specifically any ND degree programs. After National Chiropractic College complied in 1950, Dr. Budden was the lone holdout in maintaining a naturopathy program. The push in this direction was led by John Nugent, the “Flexner of Chiropractic.” In meetings of the education council of the NCA, Dr. Budden was merely resistant; behind closed doors, Dr. Budden and Dr. Nugent had loud, if personally respectful, disagreements about this subject. Dr. Budden was unyielding.122 And so the postwar period of 1946 to 1952 was a period of professional development in natural healing and of advances in clinical science and in serious scholarship. But in DC, ND education, Western States was alone after 1950. This was, at the same time, WSC’s most fruitful period under Dr. Budden fueled by the G.I. Bill—the only public funding program for DC and ND education until the rise in the 1980s of student loan and Pell Grant funding. 

hours of instruction, and summer term was 100 hours, for a total of 1000 hours the first year. This increased to 1160 for the second year, 1260 for the third year, followed by a fall and winter term fourth year of 940 hours. Degree completion for either the chiropractic or naturopathic degree came at the end of the spring quarter the fourth year.123 The first 2 years were intense with the basic sciences curriculum (as such programs are today) together with either Introduction to Chiropractic or to Introduction to Naturopathy, followed by Principles of either discipline included in the first 2 years. The students largely lived and breathed this coursework for 4 years, with most of the social activities that the students had being activities like clubs and dances at the college. This class of 1953 was mostly veterans, a bit older, a bit more ready to get to work and on with life, and mostly married. And they were from throughout the country and from British Columbia, Canada. There were eight each from Oregon and Washington; three from California; two each from Missouri, North Dakota, Minnesota, and British Columbia; and one each from Nebraska, Illinois, Michigan, Colorado, Montana, and Ohio. There were five women in the class and two African Americans, one of whom, being from Miami, had come the farthest from home to study at Western States. Emblematic of the initiative of this class of 1953, class members started a monthly news publication entitled The Synergist: Western States College Voice of the Student Body, “published in the interest of UNITY among all interested drugless healing arts.”124 This monthly publication is virtually a journal of this class of 1953, disappearing as a monthly when the class of 1953 graduated and surviving as a bimonthly only for another year or so. But while this class was enrolled at WSC, it was their voice. Another aspect of the quality of WSC and its student body, and the class of 1953, particularly, was its racial integration. Two members of this class that entered in the fall of 1949 were male African American students who graduated with the class of 1953. One of these students came completely across the country, from Miami, Florida. Jackie Robinson “broke the color barrier” in baseball in 1947. President Truman desegregated the American Armed Forces by Executive Order in 1948. The Warren Court did not strike down the segregation concept in public education until 1954. The enrollment of these two students and their integration into the graduating class of 1953 speaks volumes about the progressiveness of Dr. Budden, of WSC, of the students of the class of 1953, and of the city of Portland in general. The members of the class participated in two designated “fraternities,” Sigma Phi Kappa, a chiropractic fraternity founded in 1912 and chartered at Western States in 1948, and Phi Nu Sigma, a naturopathic fraternity started at Western States modeled on Sigma Phi Kappa. Phi Nu Signa announced in The Synergist for February 1953 that it was starting the process of “expanding its sphere of influence by providing for and inviting practicing Naturopathic Doctors to join its ranks to help promote Naturopathy and naturopathic principle and practice.” This last item seemed to be a parting gift from the leaders of the class of 1953 to the fraternity and also a way to stay involved themselves as new NDs.

Enter the Class of 1953

As Reported in The Synergist

By the fall quarter of 1949, the college had settled into a former lodge building at 4535 S. E. 63rd Street. The curriculum was set as well, and the students were expected to attend straight through for three quarters plus summer term in each of the first 3 years of attendance, and two quarters in the fourth year. The schedule started the first week of October and went through the end of July of the following year; the fall, winter, and spring quarters were each 3 months long, and summer term was the month of July. Each regular term was 300 classroom

The initiative of the class of 1953 becomes clear in looking at its own documentation of itself and of the larger WSC student body in The Synergist. By the time of the class of 1953 commencement ceremonies in March and July of 1953, The Synergist was publishing regular news submitted for publication by both the OACP and the ONA. This provided the student body with a regular source of professional news, and The Synergist became a publication subscribed to by the professions as well.

By 1946 the way was now clear for the Western States programs and the chiropractic and naturopathic professions to establish themselves in peacetime. In the fall quarter of 1949, the Western States class of 1953 entered the college. By the time the class of 1953 graduated, the majority had finished with both DC and ND degrees, and the graduating class of the School of Naturopathy was the largest class of ND degree holders ever at WSC. It was also the largest such class anywhere for another 30 years—until the John Bastyr College of Naturopathic Medicine in Seattle graduated its first full class in 1982. The class of 1953 would make its mark in keeping alive both broad-scope chiropractic in Oregon and elsewhere and naturopathy in Oregon, Washington, and the Canadian province of British Columbia for that same 30-year period. In the immediate postwar period, 1946 to 1952, the AMA—or organized medicine—was consolidating its power within the US healthcare system. Medical dominance was present, but as a threat to alternative practitioners, it was not yet at full throttle. This was, looking back historically, because of the AMA’s obsession with the threat that organized medicine called “socialized medicine”—a healthcare system controlled by the federal government.120 

The AMA and President Truman

CHAPTER 4  In the postwar era, Western States became a fixture of natural healing under Dr. Budden. The Synergist captured this in documenting the professional activities and meetings that took place at the college and the participation of Dr. Budden, the faculty, and student body in these events. As an example, The Synergist for May 1952 recapped the annual OANP meeting that had been held at WSC in March 1952, at which the featured keynote speaker had been Henry J. Schlichting Jr., ND, national president of the ANPSA.125 The same edition of The Synergist reported the complete program for the annual meeting of the Oregon Association of Chiropractic Physicians to be held at WSC the first week of June that year. Dr. Schlichting, it was reported, had given an open speech to WSC students and staff, to physicians, and to the public, as well as a speech to the convention banquet. The Synergist reported in the column “Naturo-News” authored by Dr. R.A. Rombaugh of Independence, Oregon, that Dr. Schlichting “lauded the pioneers and early educators and complimented Dr. W.A. Budden, Western States College Director on the fine job in building the College to today’s high level of standards.” The schools Dr. Schlichting said, were “the life blood of any profession.” Another initiative of the class of 1953 was an annual WSC picnic. The first reported “WSC Annual Picnic” was to be held Sunday, June 15, 1952, but was postponed a week due to inclement weather. But when it was held on June 22, 1952, as reported in The Synergist for July 1952, it left all attendees and participants “looking forward to the picnic next year.” More impressively, the picnic was attended by both members of the Oregon Association of Naturopathic Physicians and the Washington Association of Naturopathic Physicians, as reported in the Journal of the American Naturopathic Physicians and Surgeons Association (vol. 5, no. 2, June 1952). 

More Professional Matters for Dr. Budden Three other events of interest occurred during 1953 that affected the class and were noted in The Synergist. First, the Oregon chiropractic scope of practice came under assault again, from the medical profession on one side and the “straight” chiropractic group on the other. A breakfast meeting of the Oregon Joint Legislative Council held Saturday, March 7, 1953, was broadcast on radio and moderated by radio commentator (and future Oregon governor) Tom McCall. The specific subject was pending Senate Bill 134, yet another bill to strip obstetrics and minor surgery from the Oregon chiropractic scope of practice.126 Dr. Budden appeared with another physician from the OACP representing the Joint Legislative Committee of chiropractors and naturopaths. The medical view was provided by representatives of the Multnomah County Medical Association, both of them clinical professors at the University of Oregon Medical School, one in OB/GYN and one in general surgery. When asked by McCall about the fact that Palmer College did not teach these subjects as “The Fountainhead” of chiropractic, Budden related some of the history of “straights” and “mixers” and told the audience that one major issue was that the Palmer school did not wish to go to the expense of teaching these subjects even though it had adopted a 4-year curriculum in 1953. By the following Tuesday, the Oregon Chiropractic Research Association—the Oregon “straight” organization, a group in Oregon about one-fourth the size of the OACP—had issued a strongly worded communique to the radio station that broadcast the discussion and to The Oregonian newspaper. The statement said that the OCRA had nothing to do with the pending legislation and no interest in it, but it took offense at Budden’s characterization, noting that Palmer devoted 4485 class hours to “straight” adjustment technique and that Budden “attempted” to teach a laundry

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list: spinal adjustment, obstetrics, surgery, eye-ear-nose-throat practice, proctology, proctology, removal of tonsils (by electrotherapy), administering anesthetics, use of hypodermics, electrotherapy, hydrotherapy, physiotherapy, “and such” in 4240 class hours.127 In the long run, once again, no legislation was passed, altering the Oregon scope of practice.

Some Positive Developments What did pass at the insistence of Dr. Budden and Western States College, and with the support of both professions, was House Bill 271 (NDs) and 272 (DCs) increasing the educational requirements to high school plus 2 years of college credit from an accredited college or university. This was noted in an approving editorial in The Synergist for February 1953, penned by Appa Anderson. Finally, it was noted in The Synergist for March 1953 that as president, Dr. A.R. Hedges was bringing the American Naturopathic Physicians and Surgeons Association convention to Portland that summer, in July. The general chairman for the convention was WSC’s Professor W. Martin Bleything.128 

1953 for the Class of ‘53 The April 1953 issue of The Synergist contained a column by the editor of the O.A.C.P. Journal; this column had by now become a regular presence in The Synergist. The editor was A.C. Johnson, WSC class of 1951. He paid a special tribute to the class of 1953, saying “without reservation, I would like to praise a universally qualified and most ambitious group.” He paid special tribute to those “from this group, (that) have become the working force that has published The Synergist during these past four years,” and closed with: “To the class of '53, and with gratitude to you who have done so much to keep the college, the students, and the profession interested and united, we, the profession, wish you God speed in the gratifying endeavor that awaits you.” And then this remarkable class prepared to graduate and pass into the history of Western States. For some comparison, in June 1949, WSC graduated 36 DC degrees and 16 ND degrees, with 11 graduating with dual degrees. In March 1950, WSC graduated 29 DC degrees and 2 ND degrees. In March 1951, 21 DCs graduated and 4 ND degrees. In March 1952, 31 DCs and 1 ND graduated. The class was scheduled to graduate in March 1953, and most were graduating as DCs. Because there was interest expressed among class members in receiving dual degrees, a special spring quarter schedule had been arranged, focused exclusively on ND therapeutics. The Synergist had reported this development from time to time over the 1952–1953 school year. It was noted in the March 1953 publication: “much of the class will be around after Graduation to take a post-graduate course in Naturopathy, so we really won’t be saying our goodbyes for a while” This course for DCs required a full spring quarter of coursework in Cyriax’s Text-book of Orthopaedic Medicine, Volume II on massage therapy, Mausert’s Herbs for Health, and Spitler’s Basic Naturopathy in a course designed by Drs. Budden and Bleything. The class of 1953 had two commencement ceremonies, one in March and one in late June. In March, 33 DCs and 2 NDs graduated, with 7 DCs also receiving the BTS degree and 1 ND receiving the BTS degree. In July, at a special commencement at the end of the spring quarter, 33 NDs were graduated, and 1 received the BTS degree. Twenty-six of these degrees went to DC graduates from March 1953, three went to March 1952 DC graduates who returned for the spring quarter course, and six ND degrees were received by ND candidates who finished studies in June with the extra quarter’s work. The late-June ND degree ceremony was staged as an evening event on the second night of the ANPSA convention, as reported in the Journal of the ANPSA for September 1952 (vol. 6, no. 6). “The

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commencement address was delivered by that outstanding authority on nutrition of the University of Missouri, William Albert Albrecht, Ph.D. Dr. Albrecht’s address was indeed inspiring, not only to the graduates but to all in attendance.” And, as the reporter noted: “It was indeed an inspiration to see this fine young group of naturopathic physicians entering the profession. The profession needs more young naturopathic physicians to assure its future.”129 

Some Stalwarts of 1953 Joseph Boucher, the ND degree graduate who had been student body president for 1952 to 1953, received the William J. Gallagher award as the outstanding graduate of the class of 1953, with Appa Anderson being noted by Dr. Budden in announcing the award as a close second. And then the class of 1953 left Western States to conquer the world. But this class was the fruition of all that Dr. Budden and the chiropractic and naturopathic professions had built at Western States in the face of challenges and opposition. Dr. Budden died unexpectedly in August 1954, less than a week after returning from attending his last NCA meeting.130 By the time the class of 1953 finished its first year at Western States, the ND program was the only remaining ND program in the United States.131 Within 2 years of the death of Dr. Budden, the ND program at Western States was discontinued; courts had restricted the legal scope of practice in Washington and Arizona; and licensing of NDs was lost completely in Texas due to actions by the courts and in South Carolina, Utah, and Florida by legislative action. How this happened is another piece of history still to be told, but a great deal of it curbed broad-scope or “mixer” practices in those states, and a large factor was medical dominance, what the educators and physicians discussed here had battled for 25 years. Things did not improve until at least the 1980s, another part of the story yet to be told. But that should in no way diminish what was done at Western States College and in both its School of Chiropractic and its School of Naturopathy. From the class of 1953, Joseph A. “Joe” Boucher, ND, BTS, became a giant of Canadian naturopathy in his own right,132 Appa Anderson stayed at Western States for an impressive career of her own in chiropractic radiology,133 and Professor W. Martin Bleything was one of the founders of today’s National University of Natural Medicine, together with one of his fellow faculty members and a former Western States student from the class of 1952.134 Ralph M. Failor, who—along with his wife Hazel—received a DC degree in March and an ND degree in July, would succeed Dr. Budden as president of WSC. He would in time become a big part of the history of WSC.135 What happened was remarkable and needs to be better known. 

PART TWO: WHAT HAPPENED TO THEM? Moving On There may be no more exemplary story in the development of natural healing among chiropractor-naturopaths than the story of Henry J. Schlichting Jr., of Midland, Texas. Schlichting was trained as a chiropractor in Oklahoma and moved to Texas in 1941, setting himself up as a naturopath. At the time, neither chiropractors nor naturopaths were licensed in Texas. Schlichting became a leader within natural healing professionals, first within Texas and then nationally. He became a trusted ally of both Robert Carroll and of Dr. Budden at Western States College. He and his Texas naturopaths achieved licensed status in 1949. In the early 1950s, all looked bright, and then it all turned dark. On the evening of July 17, 1953, the commencement for 37 recipients of the degree of doctor of naturopathy took place in the auditorium at Western States College in Portland, Oregon. This special commencement was scheduled as the Tuesday night program for the

1953 annual convention of the American Naturopathic Physicians and Surgeons Association, as the immediate past president of the ANPSA Henry J. Schlichting Jr. of Midland, Texas, was in attendance.136 As Schlichting had said a year earlier in a speech at WSC, the prospects for naturopaths seemed good as this WSC class of 1953 graduated, most of them as DC, NDs. But the forces of medical dominance were building, starting back home in Texas, even as Schlichting was attending the convention in Portland. Within 6 years, natural healing in the United States would be much diminished. No career demonstrates this as clearly as that of Schlichting, a remarkable man and physician who, by the end of the 1950s, had been barred by the State of Texas from practicing his chosen profession and who had lost almost everything. When the class of 1953 graduated from Western States, the leadership of the naturopathic part of the natural healing professions was in Henry Schlichting’s hands as the president of the ANA, with A.R. Hedges in line to become Schlichting’s successor. There were headwinds, though, just beginning to be felt. 

HEADWINDS Some of these headwinds had been building within the naturopathic movement itself since the 1930s. Benedict Lust criticized Dr. Budden and Dr. Carroll in early 1935 for proposing a continuing alliance based in the Pacific NW between broad-scope chiropractors and naturopaths. The 1935 annual ANA convention a few months later in San Diego was a crossroads event for ND as a profession. Lust opened the convention with a presidential address that seemed to mark a “scofflaw” phase in Lust’s career as the head of the naturopathic movement. He told the convention that he had been prosecuted—and persecuted—for issuing diplomas to “doctors” from the American School of Naturopathy without a New York State charter to do so. The State of New York, he charged, was operating as an arm of the AMA’s “Medical Trust.” Only naturopaths, he told the convention, could decide who deserved to be called naturopaths, not the state or the Medical Trust. Naturopathy needed to be accepted by the public to be legitimate, not by the state. But for the first time, Robert Carroll brought a countervailing view to an ANA convention. These countervailing visions of the future of naturopathy were the visions that played themselves out over the next 10 years within the ANA. The ANA could not be a movement run by a permanent leadership but needed to truly be a professional organization seeking to advance a natural healing profession. In adopting a new constitution and bylaws proposed by Carroll, the ANA accepted Carroll’s vision of the future over Lust’s vision from the past. By 1937 Carroll was comfortable that the ANA was in a good place; now it was time for the profession to accept that fact. At the end of 1937, as the chairman of the Executive Committee of the ANA, Carroll issued “An Appeal to All Naturopaths.” He opened by saying that he for some time he had been “alarmed and rather disappointed with the seeming indifference of many of the Drugless Physicians to our National Association.” “Progressive Naturopaths,” he said, were committed to the goal, through the ANA, that “our profession will take its place as a scientific body of learned naturopaths.” With science on its side, progressive naturopaths could, for example, “tell the world just why Sulfanilamide is detrimental to the human body, and in just what kind of cases it is fatal or contraindicated—This must be our objective if we ever hope to merit the respect of the public and our educational institutions.” Changes had been made in the ANA in 1935 “to pull our profession out of the adolescent state, which we have seemingly been unable to pass.” As part of the change in ANA structure, the leadership of the ANA also gained some input into submission of ANA professional material in Naturopath and Herald of Health in exchange for ANA dues monies

CHAPTER 4  being used to support Lust’s costs of publication. Using this position, Carroll had an article by Dr. Budden on the effects of the Basic Science Laws published in NHH. The article also appeared in one of the leading chiropractic journals. 

Revisiting Basic Science This article was written in Budden’s inimitable style and was written only a couple of years away from the Oregon 1934 ballot fight that marked Budden’s initial response to Oregon adopting its Basic Science Law. In a classic Americanism argument, Budden pointed out that a “whole generation of college-bred men and women” would be good national policy as there “should be more and evermore of our youth attending institutes of higher learning, and provisions should be made to make this possible.” But there were policies that were intended to work against “Americans who value democracy” and that had the “sinister objective, nothing less than the establishment of exclusive privileges in education.” This was where, Budden argued, the Basic Sciences Laws were directed. They were designed as a test of university-level sciences divorced from the application of the sciences to drugless, nonmedical professions. This was at a time when “the drugless world had developed its own schools and colleges; institutions of learning peculiar to human therapeutics from the non-medical standpoint, well-equipped and staffed by competent teachers.” “Drugless schools,” he pointed out, “have no state support and few endowments; they must depend on contributions from alumni and upon tuition.” And as “a great national magazine (had) brought to light the unpleasant truth [was] that more people gave allegiance to physiological and drugless methods than to purely medical treatments.” If “the drugless schools continued to flourish and to increase in value to the community and the country at large, it soon be too late to attack them. Thus the basic science idea was born.” Budden went on to argue that “it is important to note that in most states, and in the state of Oregon in particular,” the sciences called the basic sciences—anatomy, chemistry, physiology, pathology and public health—were already taught and tested on for chiropractic and naturopathy. The purpose of the “extra” examination seemed to Budden to be an attempt to raise a barrier to drugless, nonmedical students of chiropractic and naturopathy with a clear ulterior and undemocratic motive: to keep these practitioners out of the marketplace: “Proponents of the law maintain that by this arrangement, which they contend is fair to all alike, the public is assured of a higher grade of practitioner. The police power of the state should be wielded to protect the public: not one particular group of physicians. The way of safety for the citizen is not in uniformity of thought in the healing arts, but in diversity.” Dr. Budden had come to be recognized by Robert Carroll as one of the leading “schoolmen” in natural healing. Although Budden was very concerned about “a board composed of university lecturers or Deans, men who know nothing of drugless practice and care less, prejudiced even before they occupy positions on the basic science board,” he came to believe within less than 10 years of dealing with the Oregon board that the examinations were fairly held—which will be addressed later in this chapter. A similar set of countervailing visions to those playing out within naturopathy played out within the National Chiropractic Association. In 1939 the influential broad-scope (or “liberal”) chiropractor from Montana, C. O. Watkins, DC, argued in an influential article137 that chiropractors should not favor separate licensing and degree status for naturopathy; rather, chiropractic statutes should be sought legislatively, recognizing that naturopathy was incorporated within a broad conception of “liberal” chiropractic and should be recognized as such.

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In the article, Watkins noted that nationwide, there were “16,000 chiropractors, 95 per cent using other than straight Chiropractic” and “2000 naturopaths, many of them holding Chiropractic licenses who could also be considered liberal chiropractors.” Furthermore, Watkins noted, the NCA had considered the issue of backing naturopathic legislation and decided on a different policy: “That the NCA oppose any plan that would cause the passage of separate physio-therapy laws or naturopathic laws to cover liberal chiropractors, but rather favor liberalization of Chiropractic legislation where it desirable to legalize liberal practice.” Looking back through the lens of historical hindsight, it seems that these policy differences fostered a diffusion of energies that would have been better spent seeking recognition for natural healing in the most expansive way possible, wherever possible. 

And Scandals Although most developments that have been discussed thus far were positive, in the 1940s, there were scandals involving practitioners identified as “naturopaths” as well. In 1938 a group of liberal chiropractors that identified themselves as chiropractor-naturopaths had formed the American Naturopathic Association of Michigan. Their leaders were charged with bribing members of the Michigan state legislature during the 1939 and 1941 legislative sessions. The charges alleged that bribes had been paid in an effort to get a naturopathic law enacted, and reports of the investigation by an inquiry judge, including the charges brought and the trials and guilty pleas in the case, dominated upper Midwest headlines from late 1944 through the end of 1945. A much bigger scandal—one that received much wider and more sensational coverage—emerged in Tennessee. By the time the events there had played out, the courts had laid the groundwork for the assault on naturopaths that took place 10 years later in the mid-1950s. Organized naturopathy came to Tennessee in December 1937 when the ANA of Tennessee was chartered. Guy W. Cheatham, DC, ND, had established the Nashville College of Chiropractic and Naturopathy earlier in the 1930s, and the school and the ANA of Tennessee operated in an unlicensed vacuum for several years while Cheatham was active in the NCA efforts on chiropractic education and in ANA national affairs. George A. Floden, DC, ND, of Los Angeles, California, was affiliated with Cheatham’s college and lectured there on a regular basis. Matters in Tennessee changed significantly and abruptly in 1943 when the Speaker of the Tennessee House of Representatives, backed by the Crump political machine based in Shelby County (Memphis), pushed through a naturopathic licensing law over the veto of the state’s governor. A 1946 investigation suggested that two naturopaths who later were named to the naturopathic licensing board funneled several thousand dollars to the Speaker (one bookkeeping entry showed $7835 for “1943 legislature”), their golfing buddy, in the form of “friendly” golfing bets. By 1946 the examining board, which by statute kept its own books and records of licenses issued, had issued 917 Tennessee licenses to “naturopaths” from as far away as California, Alaska, Mexico, Canada, and South Africa. The number could actually have been more than 1000 licenses issued, as the books and records of the examining board “disappeared” from the offices of one of the board’s members while the records were under subpoena by state prosecutors. But investigation showed that some diplomas and licenses were sold as a package: $1500 for a diploma and $1500 for a license. In December 1946, 27 indictments were issued by a grand jury in Nashville. Those charged included Guy Cheatham DC, ND, and his California associate George Floden, DC, ND, along with a California associate of Floden. Two Texas NDs who lectured at Cheatham’s Nashville College were charged as well, and in the grand jury’s 34-page

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indictment, it was alleged that all schools of naturopathy in Tennessee were “diploma mills.” Cheatham had, admittedly, issued “naturopathy” diplomas to earlier chiropractic graduates of his college so that they could apply for naturopathy licenses after the 1943 statute went into effect. In all, 17 defendants submitted nolo contendere (“no contest”) pleas and were fined between $100 and $1000. The largest fines of $1000 went to two of the three members of the licensing board that the prosecutor said were “to blame for the conspiracy.” Charges against Flodden and his California associate were dropped when the State of California denied extradition to Tennessee on the charges. More importantly in the long run, the 1947 Tennessee legislature repealed the naturopathy act, criminalized any future practice of naturopathy in Tennessee, and invalidated all existing licenses to practice naturopathy in that state as of January 1947. Ten practitioners—all members of the ANA of Tennessee and all “clean” of any taint from the indictments—filed suit, seeking a declaration by the courts that the repealer statute was constitutionally invalid because it deprived them of their valid property interest in their licenses to practice without due process and without any finding that naturopathy itself was a threat to the health and welfare of the citizens of Tennessee. A chancery court (trial-level) judge agreed, holding that the legislature did not have the constitutional authority to rescind the right to practice a legalized profession and to revoke, carte blanche, an entire class of professional licenses from practitioners who were without fault. A request to enjoin any enforcement of the statute through prosecutions for practicing medicine without a license was denied as beyond the authority of the court. But before 1947 was over, the Tennessee Supreme Court had reversed this judgment. The Supreme Court held that the allegations of massive fraud in issuing licenses were serious enough to justify a sweeping response under the state’s constitutional police powers, without the necessity to review each license in question. Moreover, the Tennessee court held that it was well within the police power of the state legislature, under the same constitutional police powers, to repeal an entire class of professional licenses—especially in the healthcare domain—at any time, within its reasonable discretion. That is, where licensing was concerned, the legislature taketh, and the legislature taketh away. The plaintiff naturopaths petitioned the US Supreme Court for review of the case and of the Tennessee Supreme Court’s holding on these constitutional issues. Review was denied. The table was set for a later broad assault on the licensing of natural healers across multiple states in the 1950s. 

And Repercussions The mischief and the stain originating in Tennessee spread quite quickly as well. In early 1947 as the scope of the Tennessee scandal was emerging and as the Tennessee legislature was repealing the Tennessee licensing law, investigations of licensing of naturopaths began first in Connecticut and then in South Carolina. In Connecticut, the state health commissioner—by state law a position held by an MD—withheld licenses from 28 applicants who had been approved for licensing by the Connecticut Board of Naturopathic Examiners starting in 1942 because none of the applicants had passed state licensing examinations, neither the basic science examination nor the naturopathic licensing examination. All of the applicants had been approved based on a Connecticut healing arts licensing reciprocity statute. All of the applicants sought reciprocity based on licenses issued in South Carolina—a state with no basic science examination. In 1946 three applicants brought suit in two actions against the health commissioner seeking a court order directing that their licenses be issued immediately (through a writ of mandamus or “mandate”).

Both applicants had failed the basic science examination more than once and then presented South Carolina licenses to the Connecticut Board, which had approved reciprocity applications. The applicants prevailed first in chancery (trial) court, then in the Connecticut Supreme Court. The courts—the chancery court in June 1946 and the Connecticut Supreme Court in April 1947—held that the health commissioner served in a ministerial capacity, that is, the health commissioner had no discretion in issuing licenses when the Naturopathic Board had approved the applications. The courts also found that the reciprocity statute allowed the approval without examination, but the Connecticut Supreme Court agreed with the trial court that the health commissioner was trying to protect the public interest. The Connecticut Supreme Court noted further that if evidence showed that the applications were fraudulent or the actions of the Board were taken in bad faith, members of the Board should be removed from office. Based on the issues developed in the court proceedings, the Connecticut police—which had the responsibility for licensing background checks—began an investigation into the reciprocity applications that lasted 6 months. This led in turn to an overlapping investigation by the state police in South Carolina. A clear pattern was documented: applicants from schools not recognized by South Carolina (which recognized only the National College of Chicago and Metropolitan of Cleveland as of 1947), primarily applicants with diplomas from Lust’s American College of New York, had obtained licenses in Tennessee between 1943 and 1946, and then been licensed in South Carolina without examination. Twenty-four applicants had then applied for licensing in Connecticut, again based on reciprocity. An investigation done in South Carolina by two Connecticut police detectives disclosed that only four applicants had actually spent any time practicing in South Carolina, and no time had been spent in Tennessee. The South Carolina Board had suspended the practice of accepting reciprocity applications from Tennessee in February 1947 when the Tennessee legislature outlawed naturopathy, but in 1947 and 1948, legislative pressure built up on the Board, and ND licensing in the state was under threat of repeal. By 1949 the repeal threat had been survived—for the present. Much of this was a result of Connecticut adopting a Basic Science Law when only National, Metropolitan, Western States, UNHA of Denver, and Los Angeles College—all chiropractic colleges with ND degree programs—had legitimate 4-year residency programs with a basic sciences curriculum. How had this been worked through by these colleges? By 1944 Dr. Budden’s view of the Oregon Basic Sciences Examining Board had changed based on 10 years of experience with the Board and its examinations. 

More Basic Science In the October 1944 issue of The National Chiropractic Journal, Budden offered his updated assessment of the Oregon Basic Science Law in the article “Effects of Basic Science Law in Oregon.” By this time, Budden noted that “we should like to make it clear … that we—the faculty and myself—have had some ten years of experience with the preparation of students for this test and, as a consequence, we feel that we make speak with some authority.” This notwithstanding that “public and candid discussion of the merits and demerits of basic science legislation has been regarded as a species of treason to Chiropractic (and Naturopathy).” But strictly directed to the Oregon experience, the Basic Science Law in general had shown his students to be ready join “one of the learned profession,” passing an examination given by a board of college and university professors chosen by the Board of Higher Education that “conducts its affairs with equity and intelligence (with) examinations

CHAPTER 4  that are fairly held and the papers fairly marked.” From all the evidence Budden had observed—and from a success rate of 25 out of 30 students passing the examination the first time (83.33%)—Budden believed “that if a student follows the courses covering the required subjects as they are given in the accredited schools, faithfully and with diligence he will pass the test.” He still noted that the public health part of the examination was based totally on the medical approach to the subject, requiring that the faculty had to teach students both “traditional” public health and the nonmedical alternative thinking. But he felt this was a price to pay in order that a higher level of nonmedical education was achieved, medical propaganda about a low level of nonmedical education was “wiped out,” success on the examinations favorably influenced the courts and the legislature, and there was more favorable treatment of the nonmedical professions by the outside the medical domain “all-around.” Finally, Budden noted that “of late efforts have been made to circumvent the law by setting up very dubious and possibly illegal ‘reciprocity.’” This, he said, was self-defeating: “There is only one way; to qualify enough candidates to show that the level of education makes two [licensing] examinations for the right to practice the healing arts preposterous.” In this thinking, as in many respects, Dr. Budden was almost 40 years ahead of his time. 

Dr. Schlichting Henry J. (Hank) Schlichting Jr. was born in Fowler, Kansas, in 1915 and was raised—or, as he put it, “reared”—in Weatherford, Oklahoma. By 1938, at age 23, he had graduated from Oklahoma City’s Carver Chiropractic College and relocated to Amarillo in the Texas Panhandle, where he joined “Dr. Roy G. Moore’s Chiropractic Hospital—Serving the Entire Southwest” as “Assistant Specializing in Dislocations and Fractures.” By the fall of 1941, he had relocated to Midland, Texas, and opened his own practice, the Modern Health Clinic. He advertised himself as “Dr. Henry Schlichting, Jr., Naturopathic Physician Specializing in Fractures and Dislocations.”138 How Schlichting came to call himself a naturopath is somewhat unclear. In the mid-1930s there was no licensing in Oklahoma or Texas for either chiropractors or naturopaths. Carver Chiropractic College in Oklahoma City taught obstetrics, minor surgery, and a broader use of adjustive technique than “straight” chiropractic. Texas was mostly dominated by straights through the influence of the Texas Chiropractic College in San Antonio. Although Schlichting’s early training was in chiropractic, and he was first in chiropractic practice in the Amarillo, Texas, area when he settled in Midland in 1941, he allied himself with the naturopaths in Texas and always called himself a naturopath.139 Also, by the fall of 1941, he had joined the newly formed ANA of Texas. At the organization’s first statewide convention in Dallas— attended by more than 500 initial members—he was elected secretary-treasurer. This quick ascension into the leadership ranks of the naturopaths of Texas led in turn to his connection with the western ANA group and with Robert V. Carroll.140

Dr. Schlichting and the Western ANA The 1942 convention of the ANA in Chicago was boycotted by Benedict Lust, Jesse Mercer Gehmann, T. J. Schippell, and their allies that became the eastern group. They held a “rump” convention of about 75 eastern naturopaths in Atlantic City in anticipation of the Chicago convention electing someone other than Lust as ANA president. In Chicago, Fredric Dugdale of Portland, Maine, was elected president. The president of the ANA of Texas, which since its formation in 1940 had delivered the biggest state representation to the ANA, was H. A. Brown of Canyon, Texas. He was elected first VP of

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the national ANA under Dugdale (Robert Carroll stayed as chairman of the Board of Directors), and in 1944 Brown was elected national president. When Carroll succeeded Brown as ANA president in 1946, he tapped Schlichting as his secretary.141 What made Schlichting stand out to Robert Carroll must be guessed at, but Carroll was a superb leader and organization man, and he recruited many significant naturopaths into the profession and into the western ANA. He recruited John Bastyr and many others in Washington State into naturopathy before moving on to the national stage. Schlichting had much to commend him: he became a strong ally of Harry Brown in the Texas ANA, an organization that grew to more than 400 members, most of whom also joined the national ANA; he was a talented writer and speaker; and he was a strong organization man. Once he was placed as national secretary by Carroll, Schlichting brought all of these talents to the national ANA. He continued to advance naturopathy in Texas, and he built a busy, thriving practice in Midland. Throughout the 1940s he advertised specializing in fractures and dislocations. Midland was a western Texas oil town, and oil roughneck work was notorious for its physical toll. The Carver techniques emphasized minor surgery and a “structural” approach to chiropractic. This became known in chiropractic as the Carver Technique, and as it evolved, it became one of the roots of naturopathic physical medicine.142 

More Background on Clinical Practice Willard Carver “opened the Carver-Denny School of Chiropractic in Oklahoma City in 1906, which in 1908 became the Carver Chiropractic College Carver’s philosophy gave equal importance to any anatomically produced ‘nerve occlusion,’ whether or not related to the vertebral column, while his structural approach to biomechanics became more ‘holistic’ than B.J.’s [Palmer] segmental one-bone-out-of-place approach.”143 Carver established four chiropractic schools, in New York City; Washington, D.C.; and Denver in addition to Oklahoma City. It was the Denver school that became most significant to natural healing education and clinical technique. As Walter Wardwell described the relevant history: “Homer G. Beatty (1897–1951), who had graduated from Carver’s Oklahoma school in 1922, became the dean of the Colorado school in 1923 and its president in 1924, serving until his death in 1951.” In 1939 Beatty published Anatomical Adjustive Technique. By 1935 the school was reorganized as the nonprofit University of the Natural Healing Arts, which offered three doctoral degrees, D.C., N.D. and D.P.T. [Doctor of Physical Therapy], the last requiring 3 years of study rather than the 4 required for the others.”144 Homer G. Beatty, DC, ND, is a part of the story of the professionalization of natural healing for several reasons. He was a part of the educational efforts of the National Chiropractic Association from its commencement in the early 1930s. He adopted the 4-year residency educational model for the UNHA DC and ND degree programs in lockstep with Budden at Western States. Although Colorado did not adopt licensure separately for NDs, his ND program at UNHA provided about half of the licensed NDs in the neighboring state of Utah by the mid-1950s. And perhaps most importantly, his book Anatomical Adjustive Technique, which described methods of treatment by manual adjustment for the entire anatomy, became a cornerstone for natural physical medicine. It was this type of clinical technique that was used by Schlichting in his West Texas practice. These clinical techniques were supplemented by the treatment methods illustrated in Alton Johnson’s Principles and Practice of Drugless Therapeutics, the first edition of which was also published in 1939. Johnson, another DC, ND, covered physiotherapy,

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electrotherapy, and hydrotherapy—in addition to adjustive technique—in his book on clinical science for natural healers. Both of these works were integrated by Budden into the postwar curriculum at Western States, and both Beatty and Johnson became members of the western ANA after the war. In Johnson’s case, he was recruited by Carroll and Schlichting to attend the 1948 western ANA convention in Salt Lake City and prevailed upon by them to accept the chairmanship of a new ANA committee on physiotherapy. In this position, Johnson wrote or edited a regular physiotherapy column in the journal of the association for several years (while also writing regularly for the journal The Scientific Chiropractor), and in the early 1950s he served a 3-year term on the national association’s Board of Directors.145 These were the clinical techniques at the center of Schlichting’s clinical practice during the 1940s when he established his practice and became a leader in the national movement of natural healers. He also became a civic leader in Midland, as a prototypical American joiner of voluntary civic associations: the Lions Club, the Jaycees, the Toastmasters, and various civic improvement efforts. Dr. Schlichting, or “Doc” to the citizens of Midland, practiced and lived very visibly in his adopted hometown, as many members of the western ANA did in the 1940s before natural healing came under assault by the AMA in the 1950s. 

Back to the National Scene As a national officer by 1946, Schlichting found himself in the middle of the dispute over control of the American Naturopathic Association, chartered in Washington, D.C. by Benedict Lust in 1919. After the “pseudo-group insurrection” of 1942, Lust remained embittered and denied the legitimacy of the “western ANA” until his death in August 1945. But for these 3 years, the nation was at war, and many were diverted from much of civilian life. The westerners largely built a communication network, held annual meetings, and waited out the war. Peacetime would come, and by circumstance, when it did, Benedict Lust had died. Then in peacetime, internecine warfare broke out among the naturopaths, as both Carroll and his western group and the eastern group led by Jesse Mercer Gehmann, T.M. Schippell, and a new face, Paul Wendel, laid claim to the “ANA.” Working with Carroll, Schlichting and a few others built up their Western “pseudogroup” while defending their right to being “the real ANA” and while constantly pushing the concept of unifying all naturopaths within one organization.146 Looking through the historical record, it seems clear that Robert Carroll had followed a methodical campaign to make the ANA into a true professional organization and that he had done so by amending the ANA constitution, bylaws, and governing structure. The western group had every right to be recognized as the legally constituted ANA organization as WWII ended, and Carroll’s ANA represented the broad-scope practitioners from the urban areas of about 20 states, including all of the licensed states. The eastern group that survived Lust, though, continued his dispute of their claim of legitimacy from 1946 to 1950, and the issue was a constant distraction.147 Through 1946 and 1947 the western group, for various reasons— including a postwar paper shortage—struggled to produce a monthly publication for its membership. During this time the leadership communicated with members through a series of “Dear Doctor” newsletters that Schlichting sent out from his Midland, Texas, office as “American Naturopathic Association, Inc., Office of the Secretary.” In January 1948, at long last the Journal of the ANA debuted, and the western ANA became a more established presence on the cultural, political, and professional scene. With much anticipation of a “Unity Convention,” the group convened in July 1948 in Salt Lake City,

Utah, for its annual meeting. Although the organization had grown in strength and presence—and more than 300 naturopaths attended the meeting from about 20 states—“unity” was not achieved, and Carroll passed the reins of the presidency to Schlichting.148 As of the summer of 1948, there were ND degree programs at National College of Chiropractic in Chicago, UNHA in Denver, Western States in Portland, and Metropolitan College in Cleveland, Ohio, that were legitimate 4-year residency colleges, as well as a program at the Los Angeles College of Chiropractic that was in a state of flux, although soon to be disbanded completely by the National Chiropractic Association. Schlichting took the presidency from Carroll at a time when the future for chiropractor-naturopaths looked promising.149 A historical note here is in order. Almost all of the naturopaths in the western group were chiropractors who had branched out in classic “mixer” fashion. With the exception of Robert Carroll himself, who had been a direct student of Henry Lindlahr and who had begun to call himself a “naturopath” instead of a drugless healer in the early 1930s, a historical tracking of every ND leader from the postwar era leads back to an early chiropractic college. As just two examples (Schlichting’s education has been covered), Harry Riley Spitler (the lead editor of Basic Naturopathy) graduated from Ross Chiropractic College in Fort Wayne, Indiana, before WWI, and John Bastyr (after whom today’s Bastyr University is named) graduated from the Seattle Chiropractic College in the early 1930s. Spitler was also on the faculty of the Metropolitan College from the mid-1930s until WWII. Also, in several states, “mixers” became identified as naturopaths because chiropractic “straights” took control of chiropractic licensing. Washington, South Carolina, Utah, and Texas were such states.150 

Dr. Schlichting Becomes President When Schlichting took over as president of the western ANA, things were at a critical juncture for natural healers, whether they identified as chiropractors or naturopaths both nationally or back home in Texas. Schlichting, while running a busy, growing practice and emerging as a civic leader in Midland, was up to the task of growing the ANA as an organization and achieving legal recognition for naturopaths in Texas. In doing so, he followed Robert Carroll’s model: practice openly and proudly as an “ND” and “Dr.,” be a civic leader, push constantly for recognition for naturopaths and legitimate ND school programs, and do everything possible to unify the profession within the ANA.151 As the incoming president in 1948, Schlichting had set the ANA 1949 convention for Houston, Texas, to take place coinciding with the opening of Houston’s newest—and in keeping with the mottos of Texas “biggest and best”—luxury hotel. As 200 Texas naturopaths joined with 200 out-of-state naturopaths for the ANA’s largest convention, Schlichting was able to announce to the attendees that the Texas legislature had passed a Texas licensing law as part of a legislative “deal,” and the governor of Texas was signing off on the legislation. Within 2 years, Texas was the home to more than 400 licensed NDs—the largest licensed state in terms of numbers and the largest source of Western ANA members.152 The nature of the “deal” became critical within just a few years. The Texas State Medical Association wanted Texas to adopt a Basic Science Law. The Texas chiropractors wanted a licensing law for “straight” chiropractic. An earlier law had been struck down by the Texas Supreme Court for violating a provision of the Texas Constitution that prohibited giving preference to any “school of medicine.” And the growing naturopathic group of 500 and counting wanted recognition. A group of legislators brokered a deal: a Basic Science Law would be adopted

CHAPTER 4  first; then, subject to it, a chiropractic law crafted to withstand challenge would be adopted; and finally, a pending naturopathic bill would be adopted.153 The Basic Science Law passed both houses of the Texas legislature handily, the chiropractic law was adopted by slightly tighter margins, and then the naturopathic law passed the state House fairly comfortably. But then, in a harbinger of things to come and with its Basic Science Law in hand, the state medical association tried to kill the deal with a push against the ND bill in the state Senate. The bill, after much delay, passed the state Senate by one vote, 23-22, in July 1949, while the profession was in Houston for its convention.154 

NATUROPATHS AT THEIR PEAK The Late 1940s and Professional Growth Under Schlichting’s leadership as national and state leader—and soon as a member of the first naturopathic licensing board in Texas— the profession continued to grow. But as noted earlier, the number of schools started to decline. Los Angeles dropped its program, and Metropolitan closed up in 1949. National dropped its program in 1950 under pressure from the National Chiropractic Association. Suddenly in 1951, Homer G. Beatty, DC, ND, of the UNHA in Denver passed away and with him, in short order, so did another ND program; only Western States under Dr. Budden was left.155 

In Memoriam—Robert V. Carroll, Sr. And then suddenly in March 1951, Robert V. Carroll—Schlichting’s mentor and the true “father” of the modern naturopathic profession passed away. As Schlichting and the editors of the Journal of the ANA memorialized Robert Carroll’s life and career156 In MEMORIAM Dr. Robert V. Carroll, Sr., died Friday, May 11th, of internal hemorrhage followed by coronary embolism. He died as he lived, suddenly and dramatically. There had been no prior illness. He went from excellent health to death in twenty-four hours. The naturopathic field has lost one of its greatest fighters. His was not the fight for individual stature; his was the fight for rightful and legal recognition of Naturopathy. He did not aspire to a statue, a pedestal or plaque exhorting his name in superlatives; his desire was to see naturopathy reach its honored place in the sun and to be a proud member of that profession. Now, his three score and ten has been completed. His earthly body has been laid away, but his spirit will march on. He has left a high mark on the wall. When we can measure up to it, his dream will have come true. The world has lost a man, the nation, a citizen, and naturopathy, a leader. But in our hearts each of us knows that the loss cannot be described in words alone. He admired and respected the qualities in others that fired them to opposition. In his heart he had only friends, agreeing friends and disagreeing friends. All will miss him. In the 1950s Henry Schlichting and the naturopaths faced challenging times that could not be foreseen in 1951. Robert Carroll’s leadership and vision would be missed. 

1947–1950 and Forward When Robert V. Carroll passed away unexpectedly in May of 1951, the natural healing profession that he had helped build with 20 years of diligent work was trending upward. When Dr. Carroll passed from the scene, national leadership was then held by Henry J. Schlichting Jr., of Midland, Texas, and by A.R. Hedges of Medford, Oregon. Educational

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leadership was in the hands of W. A. Budden of Western States College, Portland, Oregon, and Joseph Janse of National College of Chicago, Illinois. Texas had licensed naturopaths and chiropractors in 1949 as part of a legislative “deal” in which the Texas legislature also adopted a Basic Science Law. In 1950 the Georgia legislature had licensed naturopaths, and the Nevada legislature had also adopted licensing statutes in 1951. In the negative column at the time of Carroll’s passing, National College had dropped its formal ND degree program in 1950 under pressure from the National Chiropractic Association’s Council on Education, and the governor of the state of Nevada had vetoed the Nevada legislation just after the legislature adjourned. Joe Janse would proudly call himself a DC, ND, well into the 1960s and preside over a broad, “liberal” chiropractic curriculum at National, but the National College decision reduced legitimate, 4-year residency ND education to only Western States.157 In Texas, Henry Schlichting—“Doc” to the Midland, Texas, community—sat on a three-member naturopathic board that had processed and accepted more than 400 applications for licensing on a “grandfather” basis that was part of the 1949 legislation. Texas became both the largest state membership base for the western ANA and the largest licensed state in naturopathy. The natural healers seemed to have weathered the Tennessee scandal by 1951 and to have absorbed the lesson that H. Riley Spitler called “Remember Tennessee.”158 Naturopathy in Connecticut159 could have suffered much more than it did in the aftermath of the Tennessee scandal, but the Connecticut Supreme Court ruled in April 1947 that the Connecticut State Board of Naturopathic Examiners—not the state commissioner of health, a medical doctor—was the legal decision maker in licensing. As early as 1942 the health commissioner had delayed the issuing of licenses approved by the Board when the approval was under the licensing reciprocity statute and from South Carolina, a state with no Basic Science Law and that approved schools that were not on the Connecticut Board’s approved schools list. The commissioner’s position was that the reciprocity statue required licensing by a state with licensing requirements comparable to those in effect in Connecticut. By 1946, when this issue emerged into public awareness, licenses issued in Tennessee—where the diploma mill and licensing fraud scandal was first coming to light—also started appearing in reciprocity applications. By the time two applicants, both with diplomas from Lust’s American School in New York (which had lost its state charter in 1935) and with licenses from South Carolina and Tennessee, prevailed in the Connecticut Supreme Court, the legislature had repealed the reciprocity statutes at the urging of the governor, and the state attorney general had begun a review of all existing licenses to determine whether evidence of fraud existed in the application process. The Board revoked 17 licenses on its own, and the attorney general revoked several more after a trial that focused on the scandal in Tennessee and the loose practices in South Carolina in its own handling of the reciprocity issue. Extensive testimony was introduced by the attorney general’s office about the Tennessee licensing scandal from depositions taken in Tennessee, and also about the extent to which South Carolina “rubber stamped” reciprocity application in 1945 and 1946 supported by Tennessee licenses. In the long run, the Connecticut Board emerged with its licensing authority intact for applicants who graduated from properly approved schools and after successful passage of licensing examinations. The same proved to be true in South Carolina but only after the Board there went through a major legislative scrutiny process and adverse publicity of its own.160 During the 1947 South Carolina legislative session, the state House of Representatives passed a “concurrent resolution” asking

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for an inquiry into “examinations and personal qualifications required of applicants to practice naturopathy in this state and the propriety of granting licenses therefore.” During the 1948 legislative session, the full resolution was addressed between the House and the Senate (which was more favorable to the naturopaths), instructing the state Naturopathic Board to clean up its own house and report to the legislature by the 1949 session. As reported in the press, “The assembly … asked the State Board of Examiners to look into this situation, remedy it if possible.” In February 1949, the Board reported to the legislature “that it had revoked a number of reciprocity licenses, giving the holders a chance to regain them by taking state examinations … Most did and were relicensed … But at least one holder of a license refused to accept the board’s order and has brought court action against it.” The Board requested stricter licensing laws and stronger disciplinary powers, and the legislature obliged. 

After the Scandals These two states were the most directly affected by the Tennessee scandal. Connecticut was “purged” by the actions of state authorities; South Carolina was purged by aggressive action of the State Naturopathic Board. Licensing in both states survived the Tennessee infection. As a reflection of post-Tennessee reality, the 1949 licensing of naturopaths in Texas included a specific reference in its “grandfather” provisions that provided that licenses issued in the state of Tennessee were not to be considered for any purpose, recognizing that the Tennessee legislature had acted to invalidate any licenses that had been issued.161 With a substantial base to work with in Texas, Schlichting decided that the naturopaths should address their own education issues by establishing a legitimate 4-year residency college within the state to be supported primarily by the Texas profession. Lack of “Class A naturopathic colleges,” Schlichting wrote in announcing the founding of SCNM to the profession, “is a threat to the perpetuation of our profession.” In 1951 the Southern College of Naturopathic Medicine (SCNM) was chartered, and an agreement was made with the newly named Texas Southmost College—a 25-year-old institution previously known as Brownsville Junior College and located in Brownsville, Texas, to serve as the home for SCNM. The administrative offices for were located in a building on the Texas Southmost campus, and the premed and basic science courses for SCNM students were taken through cross-enrollment at Texas Southmost. The first major event sponsored by SCNM was a 2-week postgraduate seminar cosponsored with the Texas Naturopathic Physicians Association and held on the Texas Southmost campus.162 

A Change of Identity The summer of 1951 was eventful for the naturopaths for several reasons. Meeting in Miami Beach, Florida, the western ANA changed its name to the American Naturopathic Physicians and Surgeons Association (ANPSA), reelected Dr. Schlichting as its president, and established its corporate charter and located its headquarters in Des Moines, Iowa. The reasons behind this organizational restructuring were explained in articles by Schlichting and by A.R. Hedges in the September 1951 issue of what was now the Journal of the ANPSA. The changes were necessitated, they said, by the last resistance to the newly unified ANA continuing to lay claim to the name American Naturopathic Association. The group felt strong enough to take on a “post-Lustian” identity in representing the natural healing professions. Robert Carroll would likely have never accepted this one step. He proudly carried the banner of the ANA and felt—correctly—that he was entitled to do so. But Schlichting and Hedges felt that the profession could use the new strength that came with licensed status for

naturopaths in Texas, added to the existing licensed states, to support a modern profession, a reinvigorated educational system and a staunch commitment to the vital force. Carroll had always preached the value of science in explaining the theory of natural healing and the value of supporting work like Cannon’s vision of homeostasis. Schlichting preached the value of a professional identity as “family physicians” in a general family practice that included minor surgery and obstetrics. The new professional organization, he pointed out, was formed to “promote the public health and to perpetuate and advance the science, art and practice of the naturopathic school of medicine; to accomplish such objectives by attaining high standards of naturopathic education and by constantly stimulating and furthering the profession’s interest in and knowledge of the diagnosis, treatment and prevention of … disease and ill health.” As things trended upward for scientific natural healing in 1951, it was through this vision.163 

Medical Dominance Arises But all of this began to change dramatically in 1953, and what seemed so promising at the beginning of the 1950s was totally eroded by the end of the decade. No developments demonstrated this as much as the history of natural healing in Texas over just 10 short years. The force of medical dominance began to rear its head in 1953 at the annual convention of the AMA. A resolution was introduced by the Alabama delegation to the House of Delegates to attack chiropractic and naturopathy at their “weakest point,” their school and colleges. At the behest of AMA leadership, this topic was referred to the AMA educational committee rather than passed on by the House of Delegates. The educational committee felt that the AMA should refrain at the time from weighing in directly on the schools and colleges of other professions for political reasons, but the sentiment of the resolution was taken by AMA leadership as a strong interest by the medical profession in moving politically against these remaining “healing cults.” The matter was passed back to the state medical societies to deal with at the state level, with the full support of the national association.164 Historian Monte Poen called the AMA “the country’s richest and most influential post-World War II lobby.” In assessing the powerful effect of the AMA’s lobbying, Poen (from his research in the 1970s) noted that “As to the role played by organized medicine, I have become more impressed by the medical community’s ability to influence public opinion” in the post-WWII 1940s and 1950s.165 At the state level, organized medicine used its ability to influence public opinion to sway the views of mainstream newspapers, government officials, and state legislators. This was important because professional legitimization is established in the United States on a stateby-state basis. This has been true since 1889 when the US Supreme Court decided Dent v. West Virginia. The history of this first medical licensing case is the subject of James Mohr’s Licensed to Practice: The Supreme Court Defines the American Medical Profession.166 Dent, the petitioner in the case, was an Eclectic physician at a time in history when there were three schools of medicine: the Regulars (called “allopaths” according to Samuel Hahnemann), the homeopaths (as homeopathy was conceived by Hahnemann), and the Eclectics (which included the physio-medicalists). The Regulars in West Virginia founded the West Virginia Medical Society in 1867 and were the moving force behind the state licensing law adopted by the state legislature in 1882. By adopting legislation that required education at a Regular school, the licensing law barred practitioners from the two other schools of medicine from practicing in West Virginia. As David Korostyshevsky summarized the key aspects of the situation in his review of Mohr’s book in the Journal of the History of Medicine167:

CHAPTER 4  Grounding his analysis in both legal and medical historiographies, Mohr argues that while the American public supported public health efforts to control epidemic disease, medical licensing was not a popular reform. It was instead “a consciously engineered policy, drafted and passed through the concerted efforts of a specific subset of physicians, the elite Regulars” of the Medical Society of West Virginia (156 of Mohr). Mohr also challenges the interpretation that medical licensing was a response to the growing complexity of scientific medicine. Because scientific medicine did not produce tangible results until the 1930s, the push for medical licensing is a consequence of economic and political factors, not strictly scientific ones. Finally, Mohr shows that the Supreme Court upheld a version of medical licensing that relied on the quality of a physician’s education as the only measure of competence. Because the Regulars were the largest of the three schools of medicine in 19th-century America, the Dent decision allowed the Regulars to achieve the elimination of the two other schools on a state-by-state basis, which, by the early 20th century, went a long way toward eliminating the other schools. 

THE BEGINNING OF THE END The Texas Medical Wars All of this became relevant to events in Texas just as the naturopaths under Schlichting’s leadership had begun to achieve success professionally and to create an educational institution that would fill the void left by the NCA decision to require chiropractic schools to abandon the training of naturopaths. As Schlichting transferred the presidency of the ANPSA to Hedges in 1952, he focused even more on his position as secretary of the Texas State Naturopathic Examining Board.168 After Robert Carroll’s unexpected passing, Budden and Hedges further advanced natural healing in Oregon—and tried to secure natural healing throughout the Pacific NW. Schlichting tried to do so in Texas at the same time, hoping to secure the Southwest (Texas in addition to Arizona) for natural healing as well. The success of the naturopaths in Texas was targeted by the Texas Medical Association and the Texas Medical Board in 1953. The medical campaign against the naturopaths began in a remarkable way. When the 1949 legislature adopted the Texas Naturopathic Act (Article 4950d, Vernon Codified Statutes), its passage was during the term in office of Texas Attorney General Price Daniel (1947–1953). When Schlichting, as secretary of the Texas State Board of Naturopathic Examiners, sought guidance from the attorney general (AG) on the “grandfather clause” of the Naturopathic Act in 1952, that guidance was provided under AG Opinion V-1486, dated July 29, 1952, directed to Schlichting as a state official seeking a necessary interpretation of state law. Such guidance to state officials was—and is—a function of the AG’s office under the Texas Constitution and Texas law. In 1953 Price Daniel—later a US Senator (1953–1957), governor of Texas (1957–1963), and justice of the Texas Supreme Court (1971– 1978)—was succeeded as AG by John Ben Shepherd. Shepherd’s office received a letter requesting consideration of two questions challenging naturopathic validity under the Texas Constitution from the criminal district attorney of San Antonio, Texas.169 That district attorney was considering bringing action against naturopaths in Bexar County, Texas, if the Naturopathic Act should be invalid. This action was being requested by the county medical society and state medical association. In this situation, the Texas AG can—on a discretionary basis— serve a unique function, that of “an alternate Supreme Court.”170 This

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function is discretionary, but with the matter under consideration by a new AG, briefs were solicited by the AG’s office and submitted on the issue. In spite of “three very able briefs” arguing in favor of the enforceability of the Naturopathic Act, G Opinion S-60, dated June 29, 1953, was issued, finding the act to violate the Texas Constitution: “SUMMARY: The Naturopathic Act, Article 4590d. V.C.S. violates the provisions of Art. XVI, Sec. 31 of the Constitution of Texas in that it gives a preference to one segment of the healing arts. To rule otherwise would require a holding that the Act is uncertain and indefinite and thus unconstitutional. State Ex. Rel. Halsted, 182 S.W. 2d 479 (Tex. Crim. 1944).” The complete loss of naturopathy in Texas and the end of the Texas career of Henry J. (“Doc”) Schlichting Jr., ND, would not be final for another 5 years. But this was the beginning of the end, and in the next 5 years Georgia, South Carolina, Florida, and Utah would be lost as well. Medical dominance as wielded by organized medicine was under way. The fallout for naturopaths in Texas after the AG Opinion S-60 issued in July 1953 developed slowly at first. The 1953 session of the Texas legislature had just ended 2 months earlier, so there was no immediate opportunity to seek legislative relief. At the same time, although AG Opinion S-60 had considerable meaning, it was not the same as a decision by the courts. Schlichting and the Texas NDs worked quietly behind the scenes to take stock of the situation and to plan how to proceed. Judging by the material in the Journal of the ANPSA and the Texas newspapers, a decision was made by the Texas Naturopathic Physicians Association not to publicize the problems created for the Texas NDs by the attorney general’s opinion. 

Back to Education: WSC and Natura Medicina Events for naturopaths for the rest of 1953 largely took place outside of Texas. After the very successful ANPSA convention in Portland and the Western States commencement for the ND class of 1953, the news at the end of the year was the 5-years-in-the-making publication of Natura Medicina. Within the first year of work on Basic Naturopathy, it became apparent to the primary editors—H. Riley Spitler and Pers Nelson of Connecticut—that inclusion of medicinal substances used in naturopathy would need to be reserved for later so that Basic Naturopathy would be focused on and confined to theory. President Robert Carroll of the ANA appointed a committee in April of 1947 to prepare a textbook on medicinal substances in use in naturopathy. The committee was formally designated the Natura Medica, Formulary, and Therapeutics Committee. The committee first convened to arrange committee assignments at the 1947 convention in Detroit; A.W. KutsCheraux had been appointed committee chair. Originally the sections for inclusion were vitamins, cell salts, botanicals, and endocrines.171 Correspondence was sent out by the committee to gather information from “the men in the field,” as Kuts-Cheraux reported to the 1948 convention in Salt Lake City. Several complications that emerged from this survey of the profession were outlined by the committee chair in this report: (1) many of the botanicals in use had not been “subjected to the usual chemical analyses, alkaloid and glucoside determination … physiological properties and pharmacological action is very vague”; (2) many favorite botanicals had been identified by practitioners in “homely lay terms”; (3) “many agents endorsed by some practitioners were condemned by others as of no value”; and (4) a major issue that had not been “satisfactorily settled” had been the inclusion of Harrison Act narcotics that had been legalized by the Florida courts for use. Five more years would be required to bring all of the committee’s work to its fruition.

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The end product was worth the wait in general terms; the book was cutting edge in its contents and scope.172 In addition to Kuts-Cheraux, there were major contributions to the work by Dr. Herbert Clough on the formulary of selected botanicals and by Dr. Helena Winters of Kelso, Washington, on vitamins and tissue cell salts (with assistance from Dr. H. Riley Spitler, chief author of Basic Naturopathy). Reinforced by the entirety of the book’s approach to natural medicine was what had become the organizing philosophy of naturopaths in clinical practice: health and healing were emphasized rather than conventional medicine’s prevention and treatment of disease, the vital force and homeostasis were a critical core element of the philosophy, and suppressive pharmaceuticals with their side effects were to be avoided. But it arrived at an unfortunate time, just as the assault on naturopaths and chiropractors by organized medicine was getting under way. The textbook, for instance, arrived too late to be put into use at Western States during the 1953–1954 school year. Dr. Budden’s unexpected death in August 1954 kept the textbook from ever being incorporated into the curriculum. And as events would play out, this cutting-edge work arrived as the naturopathic profession was contracted severely by governmental action in the mid-1950s. When Dr. Budden passed away, a remarkable force of nature, a remarkable liberal chiropractor, and a great naturopath was lost to the world and to natural healing. The Journal of the National Chiropractic Association for September 1954 had “A Tribute” by J.J. (John) Nugent, DC, director of education: Dr. W. A. Budden, director of the Western States College of Chiropractic, Portland, Oregon, died suddenly in Portland on August 1, exactly one week after his return from a meeting of the Council on Education of the National Chiropractic Association. Dr. Budden was one of the pioneer leaders in chiropractic education … As much as any man in our profession, he espoused and introduced high educational standards in our schools. An important and forceful representative of our interests, his authoritative voice was respected and listened to in our legislative halls … To many, Dr. Budden’s passing will mean that a great chiropractor, thinker, and educator has passed into history. And it is so! He was one of chiropractic’s great … He was a vigorous and indomitable fighter for truth as he saw it for freedom of the individual, and, above all, for intellectual integrity … We will miss him sorely, the … profession has suffered an irreparable loss … Dr. Budden was born a gentleman, and lived and died by that high code. We shall not forget him! What was true for chiropractic was true for naturopathy as far as Dr. Budden’s career and commitment were concerned. Both professions owe a deep debt to Dr. Budden that should not be overlooked and certainly not forgotten. Events were building to a devastating outcome: the naturopaths were going to lose Western States College as an educational base and Texas as a professional base. When Dr. Budden died in August 1954, Western States itself was at a critical juncture. In the 6 months before Budden passed away, the three issues that would cause such trouble for Western States after his death had begun to appear on the horizon.

WSC and Hard Times First, the postwar boom fueled by the G.I. Bill was coming to an end. It is difficult to overstate the effect on the chiropractic colleges generally, and Western States specifically, of the G.I. Bill adopted by Congress as the Serviceman’s Readjustment Act of 1944. One of the main provisions of the act was the funding of higher education for those who elected this benefit. The funding available covered all of the costs of higher education: tuition, fees, and textbooks. This was true at public and private liberal arts universities and colleges but also true at WSC. By the time the act expired, almost 3 million veterans had attended institutions of higher education nationally, paid for by the federal government.173 Second, the new matriculation requirements that Budden had established at WSC and had convinced the Oregon legislature to put into law were taking effect. In an article entitled “The Aspects of Two Years Preprofessional Study as an Entrance Requirement,” published in the Journal of the National Chiropractic Association in March 1954, Budden noted that “economically, the schools … that follow the twoyear plan must expect to experience an, at least temporary, set back in revenue, and it would certainly be unwise … for an institution to venture in [this] direction unless its financial underpinning is of the caliber to absorb the shock through the lean years.” Third, the issue of Dr. Budden continuing the WSC of Naturopathy began to become a serious irritation within the Council on Education (COE) of the NCA. Indeed, there is every indication that only Dr. Budden’s personal standing within the NCA and the COE kept the issue from becoming a more persistent matter while he was alive. At the semiannual meeting of the COE held February 11 to 13, 1954, in San Antonio, Texas, Budden raised the subject himself. The minutes for Friday afternoon, February 12, 1954, reflect that “Dr. Budden asked for a frank and open discussion on the Naturopathic issue.”174 The conversation continued for the rest of the afternoon and again the next morning, as reflected in the minutes. Dr. John Nugent “reminded Dr. Budden that the Western States College was the only remaining school on the accredited list that still conducted a course in Naturopathy.” Dr. Budden set out his position on the matter. It was better to “sustain a reputable school of naturopathy” to establish an educational standard that legislatures could look to. Legislation in both Idaho and South Dakota that would have diluted educational standards substantially had been defeated by pointing to Western States as the baseline for naturopathic education. On that note, the afternoon adjournment was taken. When matters picked up the next morning, “Dr. Budden gave a complete review of the history of naturopathy and asked the Council to give him concise opinions and expression of decision” that he could share with the WSC Board of Directors so that “future policies of Western States College could be determined.” Budden was reminded that at the midyear meeting in 1950, both Dr. Janse of National, together with his administrator, and Dr. Budden had been told to discontinue courses in naturopathy. Dr. Budden’s Canadian protégé Dr. A.E. Homewood (dean of the Canadian Memorial College of Chiropractic [CMCC], chartered in 1945) “inquired as to the attitude of the Council” if the CMCC initiated courses in naturopathy “to accommodate those Provinces in Canada that sustained naturopathic laws?” Budden also inquired “whether the Council had the right to remove a college from the accredited list if it continued to conduct a naturopathic course?” 

WSC and the NCA The consensus of the council was stated as follows: (1) The Council “would frown on” the CMCC initiating any naturopathic courses, as

CHAPTER 4  a degree or otherwise; (2) Dr. Budden was advised to tell the directors of the Health Resource Foundation as the governors of WSC that “recommended that the course and school of naturopathy as conducted at Western States College be discontinued as soon as obligations and commitments could be fulfilled or terminated”; and (3) the council “does have the right to remove a college from the accredited list if a naturopathic program was operated concurrently with the chiropractic program at an accredited school.” Three weeks later Dr. Budden presided over the 1954 commencement for a class of four ND degree recipients and 26 DC degree recipients, 13 of whom also received the BTS degree.175 This was the state of matters when Dr. Budden passed away suddenly in August of that year—1954. 

Back to Texas In 1954 Schlichting left most of the national efforts to A.R. Hedges, who had the advantage of working from Oregon and so of having a stable licensing situation around him. The year was spent in Texas getting ready for the 1955 legislative session and weathering a summer of bad news that was beyond the profession’s immediate control. Harry Hoxsey was a controversial figure before naturopathy was licensed in Texas in 1949, if not widely known outside the Southwest. After being pursued in the Midwest and charged with practicing medicine without a license for the use of his Hoxsey cancer treatment, Hoxsey opened his Dallas cancer clinic, which grew to a substantial patient volume by the early 1950s.176

The Texas Medical Wars Relevant to naturopathy in Texas, Harry Hoxsey applied for licensing in 1950 under the grandfather provisions of the Texas law, and under the statute, he was deemed qualified to be licensed. First Carroll, and then Schlichting, kept Hoxsey away from the ANA/ANPSA, although Hoxsey had his supporters. But in 1954 when Hoxsey was in the national headlines and consistently reported on in the Dallas newspapers, he was called “the Dallas Naturopath who runs a cancer clinic,” and headlines like “Dallas Naturopath Enjoined from Claiming Cancer Cure” appeared. Hoxsey, with the backing of a Pennsylvania state senator, had opened a cancer treatment clinic in the Miners Hospital in Spangler, Pennsylvania. The facility was run by the United Mineworkers Union, and the senator was the hospital’s administrator. Convinced of Hoxsey’s success in cancer treatment the full backing of the facility was arranged. But at this point, the federal government moved in to bar the shipment of Hoxsey treatment preparations from Texas to Pennsylvania and the use of the “drugs” in that state. Several months of publicity about the legal dispute joined together “naturopath” and “fake cancer cure” in news coverage. None of this would prove helpful when the Texas legislature went into session in January 1955 and the Texas Naturopathic Physicians Association (TNPA) sought to have legislation passed that would overcome the AG’s objection to the naturopathic law adopted in 1949. The TNPA legislative committee under Schlichting’s chairmanship hired a well-placed executive secretary who had been the executive director of the Texas American Legion to pursue a legislative fix to the licensing situation. New legislation was prepared with the assistance of former legislators who were practicing attorneys with an eye to resolving the AG’s constitutional concerns. The legislation—House Bill 6—was introduced in the state House of Representatives in January at the start of the legislative session. It was quickly passed out of the House Public Health Committee, catching the medical profession offguard. Then, just as quickly, members of the House started receiving a “flood of protests [that] began to pile up on legislators’ desks.” In

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mid-February, the bill was sent to the State Affairs Committee by a 92-46 vote of the House, where the legislation died.177 

More Hard Times at WSC After Dr. Budden’s sudden passing, the leadership of the governing board of WSC—the Health Research Foundation (HRF)—fell to Dr. Milton Higgens of Couer d’Alene, Idaho. Dr. Higgens was himself a DC, ND, although Idaho had not licensed naturopaths. Dr. Higgens had been the Idaho representative to the NCA for several years and had been a friend and colleague of Dr. Budden and a director of the HRF for many years as well. Higgens realized in short order that the HRF would have to succeed Dr. Budden in setting WSC policy and that he would need to find someone to take over day-to-day management of WSC as well.178 In December 1954, Dr. Ralph Failor, DC, ND, a Portland-based alumnus of WSC (a class of 1953 member) signed on to do this job. As correspondence between Dr. Failor and Dr. Higgens demonstrates that Failor was established at WSC as more of a senior VP; he managed the college day to day on-site but with tightly constrained authority. He wrote full letters to Dr. Higgens once or twice a week and sought and accepted guidance from Dr. Higgens constantly. Dr. Higgens’s guidance came in responsive correspondence, also once or twice a week. The Failor–Higgens correspondence from December 1954 through April 1955, has three constant themes: on a day-to-day, week-to-week basis finances were very tight; the prospects for the future were very bleak; and the chiropractic and naturopathic professions were no help, although they were always “supportive”—lots of “thoughts and prayers.” The professions were particularly frustrating to Dr. Failor. As of April 1955, Dr. Failor had met with the “liberal” DCs of Oregon and Washington as well as the NDs from both states and the NDs from British Columbia. The DCs in Oregon were “supportive” but more concerned that the NCA needed to help the practicing profession more than anything. Legislative matters kept arising, and Dr. Budden was not around to address these anymore. The Washington NDs and “liberal,” NCA-connected DCs needed WSC’s structural appearance for their purposes, more than the actual institution; both professional groups needed to be able to cite WSC as the “model” for DC and ND education but took the existence of the college for granted. Nothing highlighted this more than a proposal from the Oregon NDs when Dr. Failor met with their leadership to ask for financial help. As communicated by Dr. Failor to Dr. Higgens: “They asked if we would accept money sufficient to put out a Naturopathic catalogue. I said yes we would. Then, they said, well that is contingent on your [sic] writing the catalogue as we want it written.” Meetings with the Washington NDs focused on the NDs submitting legislation that would use the WSC curriculum as an educational model. Dr. Failor had received contact from both the Florida and South Carolina ND Boards asking for catalogs from WSC to document that an ND educational institution did exist. Dr. Failor wrote to Dwight James, the national executive secretary, to clarify the situation; on behalf the national AANP, Mr. James offered “that the word phytotherapy instead of Herbology, and Naturopathic Medicine instead of non-medical was to be almost a must in the new issue [of the catalogue].” By the end of the spring term in 1955, Dr. Failor had become frustrated and dismayed by what he saw as WSC’s financial status and even more so with what he saw as WSC’s financial prognosis. As early as February 1955, Dr. Failor was recommending to the trustees of the Health Resource Foundation that governed WSC that the doors be closed, but the Board refused this assessment.

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As Western State’s historian Lester Lamm described the situation in the first academic year after Dr. Budden’s death: Unfortunately for Dr. Failor, he unknowingly accepted the leadership position at the beginning of one of the most troubling periods in the college’s history. The deluge of postwar students that created the boom period dried up overnight, leaving the college to face almost insurmountable financial difficulties. In response to student demands for a better education in better facilities, the college had moved to a new campus in 1947. It had retooled its curriculum, increased its admission requirements, added new faculty and staff, and assumed additional obligations in anticipation of a financially robust future. In short, by 1955, the college was overextended. The peak year of G.I. Bill college enrollment nationally was 1947. Across the country. institutions of higher education scrambled to accommodate demand, adding and improving facilitates and faculty. As Lamm noted, WSC was part of this great national response to a newly created marketplace for higher education that became a core piece of the postwar American middle class. This cumulative effect on Western States was borne out by a March 1955 report by Dr. Failor to the HRF Board: At a meeting of the board a month later, Dr. Failor shared a compilation of enrollment data from the previous four years. The trend was beyond alarming; it prognosticated doom. 1.1.1.1.1.1.1.1 1950–51 1.1.1.1.1.1.1.3 1951–52 1.1.1.1.1.1.1.5 1952–53 1.1.1.1.1.1.1.7 1953–54 1.1.1.1.1.1.1.9 Spring 1955

1.1.1.1.1.1.1.2 177 1.1.1.1.1.1.1.4 151 1.1.1.1.1.1.1.6 125 1.1.1.1.1.1.1.8 99 1.1.1.1.1.1.1.10 68

Only 24 students were projected to enroll in the fall class. The declining enrollment through 1953 to 1954 was consistent with the G.I. Bill wave effect, and by the fall of 1954, it was known that the G.I. Bill benefits were scheduled to expire in June 1956 and were not expected to be further extended by the Congress. This meant that students who enrolled after the fall term in 1952 would at some point have to pay their own way. For the entering class of 1954–1955 (the class of 1958), the numbers were further depressed by the new 2-year college attendance prerequisite. Dr. Failor reported that of 49 solid applications for admission in the fall term of 1954, 30 were advised that they did not meet the entrance requirements, and only 19 students could be accepted. 

Dr. Failor and WSC’s School of Naturopathy Some of this was undoubtedly foreseen by Dr. Budden, and it seemed like Dr. Budden had been forced to navigate the choppy seas of being a DC, ND “schoolman” for 25 years. What his plan might have been, though, no one seemed to know. The HRF Board was now two members who had worked with Dr. Budden for years plus Dr. Budden’s replacement directly recruited by Dr. Nugent of the Council of Education of the NCA. They continually instructed Dr. Failor to stay the course and carry out Dr. Budden’s vision. It was hard, though, for Dr. Failor to see the way. As Dr. Lamm reports: Dr. Failor met with a number of naturopathic trade organizations throughout the Pacific Northwest over the subsequent months to solicit support. Most in the naturopathic community voiced support of the college, but little in the way of direct financial backing ever materialized. What did materialize, however, was the naturopaths’ growing resentment for the lack of representation on the

HRF board and at the college. The naturopathic community had not gotten over being ignored when they first brought their concerns about equitable representation to Dr. Budden in 1948. Dr. Failor’s appeal to the naturopaths for support only widened the rift between the two disciplines. Dr. Budden had always been in a position to speak to the naturopaths as one of them. This personal relationship earned over 25 years was gone. Unlike 1948, Robert Carroll was not around to tell the naturopaths to “buck up” and support the only school that they had. In May 1955, matters came to a head at a special meeting of the HRF Board with the naturopaths of WSC, plus members of the naturopathic and chiropractic professions from Oregon, Washington, and British Columbia—those most affected by developments at WSC. This meeting followed a meeting on the evening of Thursday, May 12, 1955, of Dr. Failor, Dr. Higgens, and Dr. Williamson, the secretary of the HRF Board of Trustees. Also present by invitation were two well-placed DC, NDs, Drs. Ralph Hill and Ross Elliott. The discussion focused on the “paramount” financial issues: that monthly revenue was $4000, whereas expenses were $500; with faculty underpaid, fixed costs deemed “excessive,” and “old, delinquent accounts” also deemed excessive. Further discussed was that the HRF trustees were constantly accused of falsifying the financial status (i.e., “crying poor”), carrying out a “silence campaign” (i.e., refusing to provide specifics publicly), and that “Dr. Higgens was trying to close the College.” Also, the various DC and ND professional interests in Oregon and Washington were discussed as they affected WSC. These interests were summarized in the meeting minutes: “Chiropractic: O.A.C.P. Liberals—want controls; Advertisers—want controls; Straights—want no part; Naturopaths: Nature Group—want no part; Medical Group— want shots and medicine included in the Naturopathic Curriculum at College (Not permissible under our Charter.).” In short, the professional groups either wanted much more say where the college was concerned or had no interest in the affairs of the college. Drs. Higgens and Williamson decided, according to the minutes, to “call a meeting of the Full Board for Saturday, May 14th, 1955.” In addition to the HRF Board, it was determined that the professional groups, specifically including the OACP and “officials of the naturopathic Physicians,” would be invited to provide “council [sic] and suggestions.” On the afternoon of May 14, the meeting took place. Unfortunately, a reading of the minutes of the meeting can only be summarized as “things went badly.” 

Naturopathy in the Cross Hairs Dr. A.R. Hedges—then finishing his third year as the president of the national naturopaths (now named the American Association of Naturopathic Physicians [AANP])—could not attend due to a family illness. This was unfortunate, as from the notes of the meeting, it appeared that Dr. Higgens and Dr. Hedges got along, but most tellingly, it appeared that Dr. Higgens and Dr. Bleything did not—or at least that Dr. Bleything was suspicious of Dr. Higgens’s longtime membership in and connections with the NCA and Higgens’s friendship with Dr. John Nugent of the NCA. One of the issues that had the naturopaths most agitated was the attitude of the Council on Education of the NCA. As Dr. Lamm reports: Sensitive information contained in correspondence and conversations between WSC and the Council on Education had been leaked to the naturopaths. Most alarming to the naturopaths was the suggestion that WSC would be denied accreditation from NCE if it didn’t discontinue offering the ND degree … A letter from the CE was read to the attendees, which clearly described its position

CHAPTER 4  regarding the relationship between the two professions. Even though the letter contained no threat from the CE to deny WSC accreditation, it was clear a “divorce” was being encouraged. The attitude that drove the Council on education—made up of the other NCA “schoolmen”—was summarized by Dr. Higgens as “[the] Association felt that WSC was taking too many Chiropractic students and making Naturopaths of them.” Higgens told the naturopaths at the meeting that Dr. Nugent—even though as the director of education for the NCA he reported to the Council, and was therefore “the Messenger”—was “recommending against great pressure that we continue Naturopathy at WSC, is fighting the battle for us in the NCA.” And in fairness, Dr. Budden did not take chiropractic students and make them into naturopaths; he took students and made them into chiropractic and chiropractic-naturopathic physicians. And as Higgens told the meeting, there “is no difference between Chiropractic and naturopathy, in this state [Oregon] where most men have two licenses—most do not know which they are practicing under.” Events over the next year would bear out what Higgens said about Dr. Nugent. Although Dr. Nugent generally did not favor dual-degree programs, he had been a staunch friend and admirer of Dr. Budden as a schoolman and honored Dr. Budden’s vision after Budden was gone. The rest of the schoolmen on the NCA Council had tolerated Budden’s position while he was alive, on the Council and in their midst. They were not inclined to be tolerant after Dr. Budden could no longer argue the case himself. Bleything told Higgens at the meeting that if naturopaths were on the Board of the HRF and therefore had more say about the future of WSC, the naturopathic profession would contribute to the college. The overriding concern appearing in the meeting minutes was that the NCA Council would threaten to strip WSC’s accreditation unless the naturopathy program was dropped and that because the HRF Board was three chiropractors now, they would abandon the ND program if the threat was made. Higgens acknowledged that this could materialize as soon as the July NCA meeting. Bleything told the meeting, and Higgens, that if the HRF Board was expanded from three to five and the new seats were given to the naturopaths to fill, the naturopaths would commit financial resources to WSC, as the matter had been put before the Oregon Naturopathic Physicians Association, stating, “If Naturopathic profession gets representation on that Board you will get $10,000 without bowing to Nugent or anybody else.” Higgens was openly resistant to expanding the Board, but when the meeting ended at 5:45 that afternoon, the HRF founders group convened to Dr. Failor’s office, and by six they announced that they had voted to expand the HRF Board to five members, at least two DCs and two NDs. Dr. Higgens had become the dominant player in the present and future of WSC since the passing of Dr. Budden. He was dedicated to the continuing existence of Western States as a chiropractic college, accredited by the National Chiropractic Association. From his correspondence with Dr. Failor, it is apparent that although he had his own dedication to the School of Naturopathy, he had no expectations that the naturopathic profession would be of any financial help in the effort to keep the school open. He had learned through Dr. Failor’s efforts not to have expectations of the Oregon DCs as well. As an executive director of the NCA, he did have expectations of the NCA Council on Education and the NCA generally. Critical to him, as a result, was maintaining NCA accreditation. On June 4, 1955, the 46th Annual Commencement of the Western States College of Chiropractic and Naturopathy was held. In spite of financial pressures, WSC was still open, and in spite of the critical observations by the Council of the NCA, 22 doctor of chiropractic degrees

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and 1 doctor of naturopathy were awarded (along with three X-Ray Technician Certificates and two Laboratory Technician Certificates). The NCA met in early July, and although the Council minutes from that meeting reflect no on-the-record discussion of the WSC naturopathy program, immediately after the Council meeting, the HRF reversed itself and reinstated the three-member Board provision. For whatever reason, no financial commitment to WSC ever materialized from the naturopaths, and as of the 1955–1956 school year, the matter remained unresolved, with the naturopathy program under a cloud.   THE END Things remained as dire as they had been during the main school year as the summer term was to begin. Dr. Failor had advised Dr. Higgens in correspondence that Dr. Bleything would organize and run the summer term on a no-pay basis. Bleything and others who similarly volunteered taught the summer term, and on September 27, 1955, 13 of the DC graduates from June received their ND degrees, and the lone ND graduate from June—Canadian Robert Fleming—received his DC degree. But neither the school nor the naturopathy program was out of the woods. Dr. Lamm writes: By the July 23, 1955, meeting of the HRF board, it was apparent to the trustees that continuing an affiliation with the naturopaths would be problematic if WSC was to achieve accreditation. At the meeting it was said, ‘We are privileged to continue naturopathy… [until] we can gracefully work out a solution.’ … It was clear by the reaction of the naturopaths that financial support for the college would not be found with them. How or why this “was clear” based on events between May 19 and July 23 does not seem clear. It seems that before the addition of two new members to the Board could be implemented, and presumably based on issues that arose during the NCA meeting in Atlantic City, July 4–8, 1955, the Board withdrew the one condition that the naturopaths put on their financial support for WSC. (The minutes of the Council on Education meeting during this NCA annual convention do not reflect any on-the-record discussion of the naturopathy program. Dr. Failor was present and participated in the 3 days of Council meetings, which focused considerable attention to the 2-year college preparation admission requirement.) How or why the naturopaths let the established WSC naturopathy program be discontinued is lost in the fog of history. It is clear that the naturopaths associated with Western States trusted Dr. Budden and worked well with the Oregon Association of Chiropractic Physicians, the Oregon NCA affiliate. Indeed, as Dr. Higgens observed, the professions in Oregon had substantial overlapping membership. But Dr. Failor, as a DC, ND, asked for help that was not forthcoming: “Dr. Failor met with a number of naturopathic trade organizations throughout the Pacific Northwest over the subsequent months to solicit support. Most in the naturopathic community voiced support of the college, but little in the way of direct financial backing ever materialized.” So the determination of whether to continue the naturopathy program or not was left to the HRF Board and its dealings with the NCA Council, which was hostile to the naturopathy program. Again, in fairness, Dr. Higgens told the Washington NDs in January and again in March that they should dispatch a representative or representatives of their own to the NCA Council to present the naturopathy program as an integral part of Western States and ask that both WSC’s ND program and its accreditation be maintained as they had been during Dr. Budden’s lifetime. But they never did so. 

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The End, Part 2 Matters came to a head during the midyear NCA Council meeting in Toronto, Canada, February 15–17, 1956, as reflected in the meeting minutes. In September 1955, as the 1955–1956 school year had begun, Dr. Higgens had stepped in to try to at least stabilize WSC’s finances: In response to a clearly desperate situation and in an effort to bring about financial stability, Dr. Higgens stepped forward on Sept. 8, 1955, and committed his personal assets by securing a $39,000 mortgage on behalf of the college and took out a $10,000 life insurance policy, naming the college as beneficiary. This was not the first time Dr. Higgens had reached for his checkbook to rescue the college, nor would it be the last. Regardless of the deteriorating situation at the college, and perhaps in spite of it, he was committed to doing everything possible to guarantee survival of WSC. If WSC had been Dr. Budden’s school for 25 years, it was now firmly Dr. Higgens’s school, governed by him and the two fellow chiropractors on the HRF Board. At the meeting in May 1955, Dr. Higgens had been openly questioned about his personal commitment to continuing WSC as a School of Chiropractic and Naturopathy. By the time of the February 1956 NCA Council meeting, it seems apparent that Dr. Higgens’s commitment was to maintain an NCA-accredited School of Chiropractic, even—or perhaps especially—if that meant dropping the Naturopathy program at WSC. Although Dr. Failor, as the day-to-day manager of WSC in-the-trenches would have welcomed the financial support of the naturopaths and could have saved the Naturopathy program if support had been forthcoming, when support never materialized, the decision was really that of Dr. Higgens. The minutes of the February NCA Council meeting tell the story. Dr. Failor had advised that he could not attend and represent WSC “because of pressing responsibilities at the college.” And, one assumes, because of the cost of attending the meeting. The meeting was scheduled for 3 days, Wednesday, February 8, through Friday, February 10, 1956. The “first point of consideration placed before the Council from the prepared agenda was the matter of the Western States College of Portland, Oregon, still conducting a course in naturopathy” (emphasis provided). The Chair of the Council (Dr. Thure Peterson) read an “extended statement” prepared by Dr. Nugent and sent to Dr. Higgens “in relation to the matter.” The position set out in the statement was to advise Dr. Higgens and the HRF Board that the Council “considers it inopportune for any of the accredited colleges to seek to sustain a naturopathic course.” The Council further “encouraged the board to consider the necessity of discontinuing the course as soon as possible, even at cost and sacrifice of certain advantages that it might represent” (emphasis provided). Council member Dr. Hendricks noted that it was time for Western States to join Los Angeles and National and “discontinue its affiliations with the naturopathic profession.” Failure to do so “would constitute an embarrassment to the Council.” Then Dr. Nugent spoke, and it was apparent that he—regardless of personal feelings on naturopathic programs—felt bound to try to honor the lifelong commitment of his friend and colleague Dr. Budden: Dr. Nugent sought to advise the Council that relinquishing the naturopathic course by Western States College would impose on the college and its board of trustees tremendous economic problems and rob it of certain allegiance … It was the conviction of Dr. Nugent that a decision by Western States College to discontinue the naturopathic course would deal a severe blow to naturopathy and that unless the profession were to organize its own school it might well represent the demise of the profession …With Western States

out of the picture of naturopathic education only two schools would be left that issued naturopathic degrees and these were institutions of minor quality and influence; namely the Great lakes College of Mechanotherapy and in Dayton, Ohio, and Spitler College of Naturopathy in Eaton, Ohio. These observations by Dr. Nugent came straight from Dr. Budden’s long-stated positions expressed during many talks on the subject with Dr. Nugent and others in NCA leadership. In deference to Dr. Budden, Dr. Nugent set this entire argument out for the Council. He then communicated that these may not be the concerns of the current HRF Board governing WSC. Dr. Nugent told the Council that “upon the death of Dr. Budden, he [Dr. Nugent] had been asked by Dr. Higgens to help manage the Western States [College] and to help solve the naturopathic situation … that Dr. Higgens, personally, had invested thousands of dollars in the Western State College [because of his intimate friendship with Dr. Budden], yet he was ready to sacrifice the same if the naturopathic problem could be resolved; that he, Dr. Higgens, was anxious to have the Western States College sever its association with naturopathic education.” After all was considered “it was the general disposition of the Council that patience should be exercised in relation to the circumstances of Western State College,” as through “the death of Dr. Budden … the present administration and board of trustees of the college had inherited many compromising and not readily solved problems.” Dr. Nugent advised the Council that he was certain that before the Council meetings concluded, “he would obtain word that “a definite decision to eliminate the naturopathic course at Western States had been consummated.” 

And Naturopathy Is Finished at WSC And so it was. As the Council convened on the morning of Friday, February 10, the Council was to hear the report of the Council on Educational Standards (Accrediting Committee). The Accrediting Committee proposed that the Council adopt a resolution that Western States “beginning September 1, 1956 … should seek to discontinue students for training in naturopathy” and “terminate its commitment to those naturopathic students enrolled.” Dr. Nugent advised that he had spoken several times to Drs. Higgens and Failor since Wednesday morning, and that they understood that this step would be necessary “although it would involve extended financial loss and … the college might not be able to survive.” Further that they had announced the day before during an all-school meeting that the decision had been made to discontinue the naturopathic course.” The Council meeting minutes note that the Council had received a copy of “A Statement of Policy on Western States College” that constituted the formal announcement of the decision to all concerned, and that the Council had responded through the Council secretary, Dr. Janse, acknowledging the “courage and integrity” that this decision had required. Within a short period of time, the naturopaths associated with Western States determined to start an independent naturopathy program, initially intended to provide an ND program for WSC’s DC graduates who were desirous of an ND degree. In July, three NDs previously associated with WSC, Drs. Bleything, Spaulding, and Stone, chartered an Oregon not-for-profit corporation, the National College of Naturopathic Medicine (NCNM). But this separation was the kind of “divorce” that left both parties worse off. Dr. Higgens had clearly hoped that the NCA would lend financial assistance to WSC with the “naturopathic issue” resolved. Instead, WSC suffered a severe enrollment decline and financial distress for almost 15 years, with average DC class sizes of 12 to 15 and a total enrollment of 50 to 60. The NCA responded with “hopes and

CHAPTER 4  prayers,” restricted accreditation, and suggestions that WSC should be merged with either Los Angeles or National—the two stronger programs with which they had a historical affinity. Meantime, the NCNM proved to be a difficult proposition, as the ND profession of Oregon, Washington, and British Columbia tried to build a 4-year residency program. It was 15 years before the program— moved to Seattle in terms of actual facilities—began to have decent attendance in the early 1970s. And all of this had taken its toll on Dr. Failor, DC, ND, as well. As Dr. Lamm reports: Dr. Failor approached the Oregon Association of Chiropractic Physicians (OACP) with his doubts that the college could survive beyond July 1, 1956. The total student population was 73 and a number of disgruntled students announced their plans to transfer to the new naturopathic program starting in the fall. Dr. Higgins appealed to the National Chiropractic Association to support a policy compelling all chiropractic colleges to adopt a two-year, pre-professional college education admissions requirement. The NCA refused to budge. By summer 1956, frustration with lack of support from the NCA, CE, OACP, NDs and DCs; compounded by the student, staff and faculty discontent on campus and a worsening financial situation at the college was more than Dr. Failor was willing to tolerate any longer. He submitted his letter of resignation to the HRF. Even though he had repeatedly recommended closure of the college and left the institution saddened and disappointed, he was effective in instituting stopgap measures that kept the college solvent. Without Dr. Failor’s efforts, the college would have closed. The educational structure of naturopaths had been severely damaged. And in Texas, the profession began to suffer damage as well. 

Back to the Texas Medical Wars The full story of the 1955 Texas legislative session where the naturopaths were concerned would not be told until the legislature reconvened in 1957, but by now, it had become well known that the AG had determined the old law unconstitutional. After the legislature recessed without action, the state comptroller refused to pay any further warrants issued by the existing Naturopathic Examining Board given the AG’s ruling, effectively putting the Board out of business.179 In January 1956, using legal counsel retained by the TNPA, the Board filed suit against the comptroller asking the court to uphold the statute and order the comptroller to pay its bills. In May 1956, the district court judge hearing the case ruled in favor of the Naturopathic Examining Board and against the comptroller represented by the AG. The district court upheld the statute as constitutional as to the licensing and registration of naturopaths and directed the payment of warrants issued by the Board. The comptroller’s office filed an appeal, and the matter began working its way through the Texas appellate courts. In 1957 matters played themselves out badly for the Texas naturopaths in a very public way.180 The 1957 Texas legislative session began in late January 1957. At the time, the appellate case on the constitutionality of the 1949 statute was pending. Henry Schlichting had been succeeded as president of the TNPA by Howard Harman of San Antonio. The naturopaths were trying in this session to once again get legislation passed that would deal with the AG’s opinion. At the end of February, Dr. Harmon went to the Speaker of the Texas House of Representatives with a tape recording on which a member of the Texas House appeared to solicit a bribe to withdraw legislation that would repeal the 1949 law and ban naturopaths from practicing in Texas.

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This led to House investigative committee proceedings, a grand jury investigation, an indictment against the legislator, and the legislator’s conviction. All of this played out between March 1957 and September 1957, with constant newspaper coverage throughout the state of Texas. It also had two unfortunate effects: few legislators wanted to have anything to do with the naturopaths while this was going on, and first the House investigative committee and then the grand jury dug up the story of the naturopaths’ activities during the 1955 legislative session. What emerged was that the naturopaths had raised a “war chest” of as much as $52,000 for the 1955 session and had spread around among members of the legislature perhaps as much as $37,000 or more to try to get legislation passed. In 2018 dollars, this would be $480,000 dollars raised and $345,000 passed out in legislative “cash gifts.” It was rumors of this type of largesse that drew the interest of a young member of the House of Representatives to Harmon as TNPA president while he was in Austin—the state capital—for the 1957 session. The bribe solicited was $5000 total, $3000 for the representative and $2000 to share “with others.” In 2018 dollars, this would be $45,000 total, $28,000 for the representative, and $17,000 to “share.” The naturopath caught up in the inquiry into the 1955 legislative activities of the Texas Naturopathic Physicians Association was Henry J. Schlichting Jr.

Texas Medical Wars Continued—1957 While the 1957 Texas legislative fireworks were playing out, the legal process was playing out at the same time.181 In late January 1957, as the legislative session was getting under way, the Texas Court of Appeals upheld the AG’s opinion and reversed the district court. The court held that the 1949 Naturopathic Act was unconstitutional, as the AG’s opinion had concluded. The legal effect, as stated by the court, was to completely undo the legislative gains that the naturopaths had been granted under the 1949 “deal” that had given the medical profession a Basic Science Law: “The judgment of the Trial Court is reversed and judgment is here rendered declaring the Naturopathy Act, Art. 4590d V.A.C.S., void” (emphasis provided). In February, Dr. Howard Harmon of the Texas Naturopathic Physicians Association tape-recorded House of Representatives member James Cox soliciting a bribe and took the recording to the Speaker of the House. In March, a legislative investigative committee was convened by the Speaker and—after an emotional “farewell” address to the House—Cox tendered his resignation, which was accepted by the governor. In April, a grand jury was convened, which took testimony about the bribe allegations and also about another matter that had emerged during the legislative hearing: allegations of a “slush fund” that had been used by the TNPA during the 1955 legislative session to “educate” House members with regard to legislation proposed by the TNPA after the AG’s opinion had been issued in 1953. If these assertions about the size of the “slush fund” and the extent of “educational” efforts were true, it had been for naught in 1955. The remedial legislation had been reported out of the House Public Health Committee early in the 1955 session—allegedly as a result of the TNPA “education” efforts—only to die before going any further. When the bill was quickly pushed through the committee process, the medical association took note, and before the matter could come to the House floor for a vote, a “flood of protests” from MDs “began to pile up on legislator’s desks,” and the bill stalled. As the House investigation was proceeding in April, the statements of a “mystery witness” were produced by the Texas Department of Public Safety (DPS). The committee abruptly stopped its hearings and referred the matter to the grand jury. In mid-April, the grand jury heard from other NDs appearing before them about the “mystery witness,” who was identified as Henry Schlichting Jr. Other NDs told the

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press that “Schlichting was the only person who knew how the association’s money was spent during past sessions of the legislature.” On April 30, 1957, the grand jury heard from Schlichting, who had given a lengthy interview and sworn statement to the Texas DPS the week before. After his appearance, Schlichting steadfastly gave “no comment” statements to the press, and never did he disclose what he testified to, nor the details of what the TNPA had done with its “slush funds” and “educational” efforts over many years. Another ND who appeared before the grand jury told the press that Schlichting “held his hand on the purse strings since 1943 and still does [in 1957].” But whatever Schlichting disclosed to DPS investigators and the grand jury in March and April of 1957, no indictments were ever issued against anyone accept Representative Cox for soliciting the bribe from Dr. Harmon. But the entire Harmon–Cox–naturopaths bribery affair had a dampening effect on both the 1957 legislative session and the naturopaths as an interest group desperately needing legislative action. In an extensive two-part investigative report,182 a reporter for the El Paso Herald-Post noted for the “Frantic Fifty-Fifth” legislative session that lobbyists had gone into hibernation when “the naturopaths got cute with their tape recorders” as the legislature began “shaking with a severe case of capital J jitters resulting from the naturopath tape recording in the Representative Cox bribery scandal.” Just as significant for the naturopaths was the direct effect on them: You won’t find any naturopaths trying to influence legislation during these nervous days. They’re now on the inactive list as far as lobbying is concerned—maybe because they figure they’ve raised their share of turmoil this session, or because they’re too busy testifying before the Travis County Grand Jury, whose deliberations are being watched with such big interest by the legislators … Dr. Howard Harmon, the naturopath lobbyist whose tape recording brought about the Cox indictment, hasn’t eased the situation any with his forecast that half a dozen lawmakers besides Representative Cox have ample reason to worry.183 In so many ways, these developments could not have come at a worse time for the naturopaths in Texas. On May 1, 1957—the day after Schlichting appeared before the grand jury as the “mystery witness”— the Texas Supreme Court refused to hear the writ of error (appeal) by the Naturopathic Board of Examiners from the court of appeals decision against the 1949 Naturopathy Act. On June 12, 1957, the Texas Supreme Court rejected a request for rehearing of the application for a writ of error, leaving the naturopaths without any further relief at the state-court level. Within 60 days, the naturopaths applied for relief from the US Supreme Court; throughout these various legal steps, the Texas courts stayed enforcement of practicing medicine violations pending the final legal determination of the validity of the 1949 law. In October, former representative Cox went on trial for bribery, and the newspapers throughout the state had the naturopaths on the front pages again. After the testimony of Dr. Harman and the playing of the recording that Harman had produced, Cox was found guilty as charged. On November 12, 1957 the US Supreme Court declined review of the Texas court decisions on the 1949 naturopathy law. 

Texas—The End On December 3, a massive statewide series of legal actions was taken across 27 Texas counties184 coordinated by the Texas AG, who vowed to “run the naturopaths out of Texas.” In the first “test case” arising out these actions taken in the name of the Texas State Board of Medical Examiners, an injunction was entered on December 9 against Henry Schlichting, enjoining him from continuing to practice naturopathy in the state of Texas without a license to practice medicine. Multiple other

injunctions were entered against naturopaths in other counties across the state. For good measure, the AG asked for—and received—an injunction against the continued existence and activities of the Texas Naturopathic Physicians Association.185 The naturopaths in Texas—about 450 of them—were in fact out of business. The case against Schlichting was appealed, and an accelerated review was granted by the Texas Supreme Court. Arguments were heard by the court in January 1958, and a decision was handed down on February 19, 1958. The Texas Supreme Court upheld the injunction against Schlichting. The US Supreme Court later denied review. The Texas career of Dr. Henry J. Schlichting Jr., naturopathic physician, was over.186 Schlichting stayed on in Midland, where he had built a solid reputation as a citizen, for another 7 years, practicing as an audiologist working for one of the largest hearing aid companies in the United States. His hearing clinics were regularly advertised, and his appearances at out-of-state gatherings of naturopaths were mentioned in the Midland and Pacific NW newspapers. Then, in 1965, he left his adopted home state of Texas and established a naturopathic practice in Phoenix, Arizona. In 1973 at the age of only 58, he died suddenly at home on a Sunday afternoon. He was taken back “home” to Midland as his resting place.187 

Three More States Fall: 1955 to 1957 With both WDC and the state of Texas lost to naturopathy, the decline of natural healing accelerated. Licensing was lost in Georgia and in South Carolina, both in 1956. In Utah and Florida—after an extensive review of the profession and its lack of educational institutions—prohibitions were put in place against any further issue of licenses as of 1957. In Florida, after a successful court challenge to the initial action, new legislation was passed in 1959 reinstating the ban on further licenses. In all of these cases, three issues turned the tide against naturopaths: no legitimate school, declining numbers nationally (from no new graduates and 450 licenses gone in Texas), and intense opposition to natural healing by the AMA and its state constituencies. Naturopaths were first licensed in Florida in 1927.188 At that time, Benedict Lust had for some years operated his second Yungborn Sanitarium in Tangerine, Florida, in the Tampa Bay region of the state. The legislation adopted defined naturopathy as a “drugless” law, consistent with pre-1939 concepts of that term: “The use and practice of psychological, mechanical and material health sciences to aid in purifying, cleansing and normalizing human tissues for preservation or restoration of health … employs heat, light, water, electricity, psychology, diet, massage and other manipulative methods.” Naturopaths were licensed in South Carolina in 1937 under the leadership of M. S. Dantzler of Spartanburg. South Carolina was a state where the early chiropractic movement was dominated by “straights,” and the “mixers” became naturopaths to achieve their own identity before the legislature. The original 1937 law was modeled directly after the Florida statute. (“The use and practice of psychological, mechanical and material health sciences to aid in purifying, cleansing and normalizing human tissues for preservation or restoration of health … employs heat, light, water, electricity, psychology, diet, massage and other manipulative methods”).189 In 1941—on the eve of WWII—the statute was amended with this addition: “The use and practice of phytotherapy, minor surgery, obstetrics and gynecology, autotherapy and biologicals shall be a part of and included in the practice of naturopathy.” The difficulties weathered by naturopaths in South Carolina from 1947 to 1949 after the Tennessee scandal have been discussed. Significantly, these problems were resolved by giving the state Board more enforcement powers so that the Board could better police the profession. 

CHAPTER 4 

The Florida Saga Begins In Florida, naturopaths in the greater Miami area of the state pushed to have the law interpreted to allow the right to prescribe drugs after the 1939 regulations were put in place at the federal level. Using the courts, this effort was successful in 1947 in convincing the Florida Supreme Court to interpret the reference to “phytotherapy” in the Florida statutes to include all drugs derived in any way from plant origins, including morphine and opium derivatives. In 1949 this created a significant—and predictable—backlash.190 In early April 1949, the State Board of Health, through its five-member governing body, adopted a resolution urging legislative action regarding “the licensing and practice of naturopathic physicians,” with a finding that: “The board has information that the practice of naturopathy including the licensing of naturopathic physicians, and the treatment of patients of licensed naturopathic physicians is being conducted in such a manner as to be detrimental to the public health of Florida.” The next day, legislation was introduced in the Florida Senate to make the practice of naturopathy unlawful in the state, and the bill was referred to the Senate Committee on Public Health. Pending the hearing by the committee on the bill, the State Health Officer, a medical doctor, picked up the attack on licensed naturopaths, who at the time numbered 239. The concerns expressed were that naturopaths had been “drugless physicians” who opposed drugs as contrary to the natural maintenance of health and natural methods of healing, that naturopaths had no training in the use of materia medica, that no other state allowed such practices by naturopaths, and that the state of Tennessee had just determined that much of naturopathic education was a fraud, yet some Tennessee licensees were among the NDs in Florida now using drugs. On April 19, 1949, the Florida Naturopathic Physicians Association ran a quarter-page ad in the Miami Herald, Florida’s largest newspaper. The ad was entitled “NATUROPATHS ANSWER THE ATTACKS OF THE STATE BOARD OF HEALTH, An Open Letter to: Wilson T. Sowder, M.D., State Health Officer.” In this “open letter,” the NDs defended their record of having “used narcotic drugs under Federal Government regulation [for] several years during which they did not abuse or misuse the privilege.” The letter further defended the way in which NDs designated their practices; conformed to the laws, including the court decisions on prescription authority and naturopathic educational standards established under the law; and questioned the good faith of an MD as “promoting monopolistic legislation … of the American Medical Association” rather than serving “the people of Florida.” The Senate committee held an all-day hearing the next day and heard a carefully marshaled presentation on these issues, including hearing the testimony of Harry Avery—the Tennessee investigator— as well as a state narcotics investigator and a regional federal narcotics inspector. The naturopaths were represented by legal counsel who was allowed to question the witnesses who appeared. More than 100 NDs attended the session. Although both narcotics inspectors argued against the NDs having prescription authority, both acknowledged under questioning that there had been no reported narcotic violations against Florida naturopaths. As the hearing closed, the sentiment of the committee seemed to be that although tighter regulation would be in order, the bill outlawing naturopathy was too much. But the record was mixed. Most of the NDs had been licensed before the Basic Science Law had been adopted. Of the 239 licensees only 22—all from National College in Chicago— had passed the BSL examination. Many practitioners had diplomas from Lust’s American College of Naturopathy; it was admitted into the record that Lust had been charged in 1934 with operating an unchartered school in New York. As the hearing closed, the committee chair

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put into the record a stack of 700 telegrams and 50 letters opposing the bill and 5 letters supporting the bill. The committee voted at about 8 o’clock in the evening to not report the bill out to the Senate by a vote of two “for” and seven “against.” One takeaway was important, though: one of the “for” votes was from State Senator Leroy Collins of Tallahassee. In the late 1950s, Collins was to become Florida’s governor.191 The staff reporter who covered the hearings—indeed, the story of the Board of Health position on naturopaths—also contributed a lengthy four-part series on naturopaths in Florida. The one school represented in Florida among the licensed NDs that was clearly legitimate was the National College of Drugless Physicians—the Lindlahr school— founded in 1908 and part of the National College of Chiropractic. About 40 alumni were practicing in Florida, and “even the critical state medical societies that have commented on naturopathic schools don’t charge that this college doesn’t offer full four-year training, even though they do complain that it does not offer a four-year course devoted exclusively to naturopathy” (emphasis provided).192 At the conclusion of the reporting on the legislative matters and the general investigation of naturopaths in Florida, the reporter concluded the series with these observations: “Better regulation, rather than prohibition is probably the answer. If naturopaths were not permitted … drugs; … prominently identified themselves as naturopaths; if stricter examination of schools … [was] required—the public and naturopathy would be benefitted.”

The Three-State Region Geographically Georgia and South Carolina share a long common border, South Carolina to the east and Georgia to the west. The common border cuts a line through a common rural area. The Georgia newspapers covered the reports out of South Carolina through the 1947 to 1949 events, and in 1950, the Georgia naturopaths had general legislative support built up for establishing a licensing board that could “cull the quacks” from the state. The acceptance of this idea in South Carolina was noted, and the Georgia legislature followed suit. Then in 1955, issues arose in both South Carolina and Florida. Geographically “in the middle,” Georgia was affected as well. The South Carolina issues started when the state AG ruled that the law did not allow the naturopaths to prescribe drugs, specifically plant-based narcotics such as opium derivatives. The NDs frankly pushed things too far when they took the AG to court over the issue. Although they won the first rounds of the legal battle, the state medical association used the prospect of NDs claiming prescriptions rights, including to narcotics, to raise the issue of these practices being a threat to public safety.193 The prescription of such plant-related drugs had first arisen in Florida in the 1940s, and the courts in Florida had held that the NDs had these prescription rights. But this issue raised conflict in Florida in 1955 as well through a series of investigative articles in the Miami Daily News entitled “Who Are the Naturopaths?” The articles—four in number—raised the same questions being raised in the South Carolina legislature: Where did these naturopaths go to school, and how has it come to pass that they can prescribe drugs and do minor surgery?194 In South Carolina and Florida, these questions in 1955 and 1956 provoked no acceptable answers. The National College program had been closed in 1950, the Western States program in early 1956. After the scare in 1949, the Florida NDs went on with business as usual. In fact, when the 1955 Miami News investigation was reported in November 1955, the only school pointed to by the Examining Board as approved was Western States. Then the program was discontinued in February 1956. Leroy Collins was now the governor of Florida, and the Miami News investigation called him out by name for his legislative opposition to

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naturopaths in Florida. Governor Collins commissioned a report from the State Bureau of Narcotics on the state of naturopathy. When the report documented that things had not seemed to have changed since 1949, he announced that one of his legislative priorities for 1957 was outlawing naturopathy in Florida.195 In 1955 South Carolina outlawed naturopathy; in 1956 Georgia outlawed naturopathy; in 1957 Florida outlawed the issuing of any new licenses to practice naturopathy. When the original legislation was struck down by the Florida courts, the 1959 legislature renewed the ban on issuing further licenses. Ultimately, the bans in these three states and Texas were upheld by the courts as within the police powers of state legislatures. In the meantime, things were not going well out West either. 

Utah

The Early Days In Utah the authorization to legally practice naturopathy first appeared in 1925 when the legislature passed legal authority for an examining board for physiotherapy and naturopathy under the Utah Department of Registration.196 The governor at the time vetoed the measure on the basis that such practices were authorized to be licensed under the state medical board as treatment by a practitioner without the use of medicine or surgery. In October 1934, there were 15 naturopaths registered with the Department of Registration through the authorization of the medical board. Finally in 1937, a separate naturopathic board was authorized by the legislature, and the legislation was signed into law this time around. In 1939 legislation was passed into law raising the educational standards for naturopaths to require 4 years of post–high school education. In each legislative session after 1939—1941, 1943, and 1945—legislation was proposed but not passed to allow for “practicing as a naturopathic physician and surgeon, including obstetrics.” But in 1946, it emerged that the naturopathic examining board had been conducting a supplemental examination for obstetrics and minor surgery in addition to a basic naturopathy examination just as the medical board had done before the examination authority had been transferred. These supplemental licenses were then issued by the Department of Registration to license holders. 

Utah Opens Up This only became publicly known in September 1946, when a second AG opinion issued in May 1946, was publicly issued and reported by the Utah newspapers.197 The story was this: In January 1946, a new department director had asked for an opinion from the AG whether naturopaths could be licensed to practice surgery and obstetrics. The AG’s Letter of Opinion answered the question no, as both surgery and obstetrics were the practice of medicine, not naturopathy. In so answering, the opinion noted that there was no such thing as “minor surgery”; under Utah law, surgery was surgery. In May, a second AG opinion letter was sent to the Department of Registration with the recognition that since 1939, naturopaths had been examined in “minor surgery and obstetrics,” and upon successful passing of the tests, they had been issued licenses to practice. This opinion noted that the statutes “were not free of ambiguity,” and therefore the practice of the Department would be deemed an existing “administrative interpretation” of the law, effective until either the legislature modified the statutes or the courts ruled otherwise. Moreover, the opinion went on to state that although licensed naturopaths could not use or prescribe drugs, those licensed to practice obstetrics and surgery could use and prescribe those drugs that “were recognized requirements in obstetrics or minor surgery.” The opinion further stated that although naturopaths could not use drugs in general practice, they could keep on hand or prescribe drugs for communicable diseases or emergencies (e.g., antidotes for poisons) in practice.

And so, as a matter of statutory interpretation, Utah became a state that allowed very broad practices to naturopaths. The legislature never did adopt any statutory language that modified the statutes interpreted by the AG, and the courts never reviewed the matter; this was the status quo until September 1955. In 1955 the Utah Board of Health—not the Department of Registration—requested a new AG opinion on the same statutory issues. At the time, the Department of Registration listed 82 naturopaths, of whom 66 were authorized for obstetrics and minor surgery.198 

And Shuts Down Again The 1955 AG opinion reviewed the same licensing statutes as the 1946 opinions and came to a completely different conclusion. Naturopaths could not be licensed to do obstetrics and minor surgery nor prescribe drugs. Under this new opinion, the Department gave notice in November 1955 that it would be canceling all of the licenses issued to naturopaths to practice obstetrics and minor surgery, effective January 1, 1956. The naturopaths appealed to the courts but lost before the Utah Supreme Court in June 1956.199 In the 1957 legislative session, legislation was passed that would have allowed the continued practice of obstetrics, minor surgery, and the prescription of drugs to “reinstate the status quo.” This legislation was vetoed by the governor after the session ended. Also, legislation was passed to fund and commission a study of the education and practices of naturopaths for the use of the 1959 legislative session. The report was devastating in its assessment of the state of naturopathic education in 1959. Essentially, the only school in existence was the National College of Naturopathic Medicine in Portland, Oregon, which at that time was in its early, rudimentary stage. Based on this assessment, no legislative relief was granted to licensed naturopaths in Utah, who were now firmly reduced to practicing without any obstetrics, minor surgery, or prescription rights.200 The 1959 legislature did pass a Basic Science Law. Naturopaths were authorized to take the midwifery examination and become licensed midwives as well as NDs but only after taking the BSL examinations. Also, naturopaths could take the obstetrics and minor surgery examinations as given by the medical board (not their own licensing board) but only after passing the BSL examination (this according to another AG opinion requested by the naturopathic board in 1961). And finally, from yet another 1961 AG opinion, naturopaths were not licensed to do spinal adjustment because by law, naturopaths were separate from chiropractic. From this point, naturopathy in Utah went into a long decline as existing practitioners retired from practice and new practitioners were scarce.201 

Washington State Under Siege In Washington, naturopaths had been in practice under the Washington Drugless Healing Act of 1919 since Robert V. Carroll had founded the Washington State Naturopathic Association in 1934. Before that time, all drugless practitioner licenses listed “Sanipractic,” and practitioners either called themselves “drugless physicians” or “Sanipractors.” Sanipractors used the initials “SP” for Sanipractic Physician. Licenses continued to be issued for “Sanipractic,” but many practitioners demonstrated their alliance with Carroll—and through Carroll’s WSNA, their alliance with the national ANA—by using the initials “ND” in practice. After adverse court decisions in 1947 (drugless healers cannot practice surgery or obstetrics), 1950 (drugless healers are not “doctors” and are not allowed standard malpractice defenses), and 1957 (drugless healers can be prosecuted for practicing medicine without a license for using “Dr.” or “physician,” conducting physical examinations), the Washington naturopaths were completely unsuccessful in getting any legislative relief over the intense opposition of the medical profession. The NDs obtained 53 signatures on a petition submitted to

CHAPTER 4  the Washington licensing department under the Drugless Healing Act and at least gained the right to be licensed to practice “Naturopathy” in Washington. For about 10 years, this obtained a little legal relief for them from some of the bad case law that applied to “Sanipractors.”202 

A Dismal State of Affairs: The 1960s This once proud and vigorous natural healing movement that existed from after WWII for about 10 years had gone into such decline—as described here—that the naturopaths’ self-reported state as of 1968 showed a professional movement almost gone.203 In 1968 consideration was given by the US Department of Health and Human Services to the request by the National Association of Naturopathic Physicians to have naturopaths accepted as independent practitioners under Medicare. As part of this process, a lengthy questionnaire was completed and submitted by John W. Noble, DC, ND. Noble was a 1937 graduate of Western States College of both the School of Chiropractic and the School of Naturopathy. As of 1968, Noble was a licensed ND in Oregon, practicing in Portland. He was NANP president and also maintained the administrative offices of the National College of Naturopathic Medicine, which had recently moved its main instructional facilities to Seattle. As of 1968, he reported that the NANP had 168 members from Washington (26), Idaho (26), Connecticut (24), Oregon (20), California (17), Kansas (16), and New York (7). Of these states, Washington, Idaho, Kansas, and New York were not considered licensed states, so almost half of the NANP membership came from unlicensed jurisdictions.

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Noble reported on behalf of NCNM that from 1960 to 1967, 16 students had graduated, and as of 1967/1968, 7 were enrolled. According to the 1965 US government publication State Licensing of Health Occupations, there were 351 licenses in effect in Arizona, Connecticut, Hawaii, Oregon, Utah, and the District of Columbia—the states still issuing licenses.204 Also, 202 licenses were renewed in Florida and California—states that were not issuing new licenses as of 1965. This was a total of 553 active licenses. Together with identifiable practitioners in the unlicensed states, there may have been 700 or so identifiable naturopaths, some practicing in extremely restrictive circumstances.

A Future Resurrection It would not be until the mid-1970s that this serious decline of natural healing in the United States would begin to be reversed and not until the late 1980s that natural healing would return to an equivalency with the profession that was built between the mid-1930s and the early 1950s by Carroll, Budden, Schlichting, and the others discussed here. That was not, obviously, from lack of commitment or effort on their part.

REFERENCES See www.expertconsult.com for a complete list of references.

REFERENCES 1. Lamm, Lester. Oregon Pioneer: The Journey of Chiropractic Education in the Northwest (Portland, OR, University of Western States); Keating, Joseph C., Jr., Callender, Alana K., and Cleveland, Carl S. III (1998) A History of Chiropractic Education in North America (Published by Council on Chiropractic Education, Scottsdale, AZ); 2014. 2. Garceau, O. The Political life of the American Medical Association. (Cambridge, MA: Harvard University Press; Truman), D., (1951). The Governmental Process (New York: Knopf); The American Medical Association: Power, Purpose and Politics in Organized Medicine. (1954) The Yale Law Journal. 1941; 63(7): 937–1022. 3. Berliner H. A System of Scientific Medicine: Philanthropic Foundations in the Flexner Era. New York: Tavistock; 1985. 4. Appleton N. Rethinking Pasteur’s Germ Theory. Berkeley, CA: North Atlantic Books; 2002. 5. Gross CG. Claude Bernard and the constancy of the internal environment. Neuroscientist. 1998;4:380–385. 6. Kirchfeld Boyle. Nature Doctors: Pioneers in Naturopathic Medicine. East Palestine, OH: Buckeye Press; 1994. 7. Lindlahr HMD, Proby CP, eds. Philosophy of Natural Therapeutics. Kent, England: Maidstone Osteopathic Clinic; 1924. Reprint 1975. 8. Ibid, note 5. 9. Ibid, note 6, p. 5. 10. Ibid, note 6, p. 8. 11. Ibid, note 6, pp. 6-7. 12. Ibid, note 6, p. 10. 13. Ibid, note 6, p. 10. 14. Ibid, note 6, pp. 28-35. 15. Keating Jr JC, Rehm WS, William C, Schulze MD. D.C. (1870-1936). From mail-order mechano-therapists to scholarship and professionalism among drugless physicians. Chiropractic Journal of Australia. 1995;25(3):82–92. Sept. 16. Ibid. 17. Ibid. 18. Ibid. 19. Ibid. 20. Ibid. 21. Ibid. Seattle meeting reported in The Seattle Times; 1934. 22. Ibid. 23. Ibid. Dr. Budden and Western States College, with its School of Chiropractic and School of Naturopathy, become part of the story in due course. 24. Cannon WB. The Wisdom of the Body. 2nd ed. New York: W.W. Norton & Co; 1939. 25. Ibid, pp. 240-243. 26. Burrow James G. Organized Medicine in the Progressive Era: The Move Toward Monopoly. Baltimore: Johns Hopkins University Press; 1977. 27. Reed Louis S. The Healing Cults; A Study of Sectarian Medical Practice. Chicago, IL: Univ. of Chicago Press; 1932. 28. See Cody, George (1985) “History of Naturopathic Medicine,” in Textbook of Natural Medicine, Pizzorno and Murray, editors, Seattle, WA, Bastyr College Publications (1993) and New York, Churchill Livingstone (1999). 29. See ibid; also see the extensive work by Susan Cayleff in Cayleff (2016) Nature’s Path: A History of Naturopathic Healing in America, Baltimore, Johns Hopkins University Press, and especially pp. 34-50 and 210-217. 30. Charles. Hazzard. Principles of Osteopathy. Kirksville, MO: self-published. republished Andesite Press; 1899. 31. See Cayleff, Nature’s Path, citing several examples. 32. Lindlahr Henry. Nature Cure; republication by. USA: ReadaClassic.com (2010); 1913:12–14. 33. Ibid, at p. 12. 34. Cayleff, Nature’s Path at pp. 54-55. 35. Bilz, F. E. Natural Method of Healing: A Complete Guide to Health (translated from the latest German edition), Leipzig-London-Paris, F. E. Bilz, publisher, through the International News, Co., New York, in the USA; 1901. 36. Ibid, at p. 7. 37. Lindlahr, Nature Cure, at pp. 17, 20.

38. Evan Willis. Medical Dominance. Sydney, Australia: George Allen & Unwin publishers; 1983. 39. Rosenthal Sau. Lewiston, Maine. Edwin Mellen Pressl; 1986. 40. Berliner H. A System of Scientific Medicine: Philanthropic Foundations in the Flexner Era. New York: Tavistock; 1985. 41. Wolinsky Fredric D. The Sociology of Health: Principles, Professions and Issues. Boston: Little, Brown; 1980:215. 42. Lipset Seymour Martin. American Exceptionalism; A Double-Edged Sword. New York: W.W. Norton; 1996. 43. Cayleff, Nature’s Path at pp. 193, 215. 44. Norman Gevitz. The DOs: Osteopathic Medicine in America. 2nd ed. Baltimore, MD: Johns Hopkins University Press; 2004. 45. Wardwell Walter I. Chiropractic: History and Evolution of a New Profession. St. Louis, MO: Mosby-Elsevier; 1992. 46. Susan Cayleff. Nature’s Path: A History of Naturopathic Healing in America. Baltimore, MD: Johns Hopkins University Press; 2016. 47. Cayleff, Nature’s Path. 48. Kirchfeld Boyle. Nature Doctors: Pioneers in Naturopathic Medicine. East Palestine, OH: Buckeye Press; 1994. 49. Lamm Lester. Oregon Pioneer: The Journey of Chiropractic Education in the Northwest. Portland, OR: University of Western States; 2014:13–14. 50. Ibid. 51. Ibid. 52. Ibid at pp. 14–15. 53. For an extended review of the concept and application of the Basic Science Law see Gevitz Norman. ‘A Coarse Sieve’: Basic Science Boards and Medical Licensure in the United States. Journal of the History of Medicine and Allied Sciences. 1988;43:36–63. 54. For an extended review of the concept and application of the Basic Science Law, see “A Coarse Sieve: Basic Science Boards and Medical Licensure in the United States,” by Norman Gevitz. 55. Budden WA. Medical Propaganda – Aided by B.J. Palmer, Defeats Health Care Amendment. The Chiropractic Journal; 1935. 56. For an extended review of the concept and application of the Basic Science Law, see “A Coarse Sieve: Basic Science Boards and Medical Licensure in the United States,” by Norman Gevitz. 57. Ibid. 58. The Oregonian. 2 Initiative Bills Will Face Voters; 1934. 59. Budden WA. Medical Propaganda – Aided by B.J. Palmer, Defeats Health Care Amendment. The Chiropractic Journal; 1935. 60. Oregon law required expenditure reporting, and $4819.03 was the officially reported expenditure filed by the “yes” campaign. The “no” campaign spent twice as much, with over $6,000 coming from the Oregon Hospital Association. The Oregonian, November 17, 1934; November 18, 1934; November 23, 1934. 61. Lamm, Oregon Pioneer, pp. 25-26. 62. Lamm, Oregon Pioneer. 63. With regard to Sanipractic, its presence in Washington, and its relationship to naturopathy, see Reed, Louis S. The Healing Cults; A Study of Sectarian Medical Practice Chicago, IL, Univ. of Chicago Press; 1932. 64. The Seattle Times, Sunday, April 24, notes a wire story Saturday—the day before—from Washington, D.C., stating that Carroll has been announced to speak before the ANA convention that July. This is the first reported connection of Carroll with the national ANA. 65. Carroll’s original diplomas are in Bastyr University’s John Bastyr archival collections, 66. Kirchfeld and Boyle, Nature Doctors, pp. 257–260, covers the relationship between the Carroll brothers. 67. The records of the Washington State Naturopathic Association including the 1930s are in the John Bastyr Archive collection at Bastyr University as maintained and donated by Kenneth Harmon Freeman, ND. 68. Lust and his publications are discussed in detail in both Cayleff, Nature’s Path, and Kirchfeld and Boyle, Nature Doctors. 69. Schlichting succeeded Robert Carroll as president of the western ANA in 1949; in 1951 the association changed its name to the ANPSA. 70. The Oregonian newspaper, Portland, Oregon, for March 9, 1952 at page 29. 71. Schlichting gave this number in an interview on the first day of the convention (Thursday); the interview appeared in The Oregonian on Friday, March 7, 1952, at p. 45.

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References

72. Licensed states were Connecticut, South Carolina, Georgia, Florida, Texas, Arizona, Utah, and Oregon. Naturopaths were licensed in Washington as drugless healers and in Ohio as “others-mechanotherapy.” 73. The life and career of A.R. Hedges, DC, ND, of Medford, Oregon, will be discussed in a future column. 74. See previous column in IMCJ. 75. Lamm Lester. Oregon Pioneer: The Journey of Chiropractic Education in the Northwest. Portland, OR: University of Western States; 2014:25–26. 76. Ibid at p. 6. 77. Keating Joseph Jr C, Callender Alana K, Cleveland III Carl S. A History of Chiropractic Education in North America. Scottsdale, AZ: Published by Council on Chiropractic Education; 1998:86–87. 78. The Western States College, School of Chiropractic and School of Naturopathy, Schedule of Classes and Hours was obtained from the library archive collection at the University of Western States. 79. The Oregonian newspaper of Portland, Oregon, for Monday, June 28, 1937, had the announcement of the commencement to be held that evening. 80. As quoted in A History of Chiropractic Education in North America, at pp. 85-86. 81. As noted in the author’s personal correspondence with Gerald Farnsworth, DC, ND, of British Columbia, Canada (June 2015). He was a personal and professional friend and colleague of Joseph Boucher, ND, WSC class of 1953, and the brother of Earl Farnsworth, ND, class of 1955. 82. The Oregonian, Monday, June 11, 1934, reports on the meeting from the week before, noting that Harold Hulme of the campaign was reelected secretary-treasurer, that Dr. Budden had passed out diplomas for the postgraduate course as well as speaking on “The Dawn of Medical Freedom,” and that Dr. Benedict Lust of New York was the principal banquet speaker. 83. A lot of the story up to 1943 is told—from Dr. Lust’s point of view—in the Naturopath and Herald of Health (NHH) volumes for July 1942, “Dr. Lust Speaking,” and January 1943, “The American Naturopathic Association Its Purposes and Objectives.” Any other volumes of NHH and any other sources will be noted. 84. The constitution and bylaws adopted in 1935 were printed and published in Naturopath and Herald of Health, November 1935 and January 1936. 85. Naturopath and Herald of Health, November, 1941; January, 1942. 86. Naturopath and Herald of Health, July, 1942; August, 1942; January, 1943; Newsletter from the American Naturopathic Association, Office of the Secretary, Midland, Texas, dated March 1, 1947, listing Robert A. Carroll as President; American Naturopath, Volume III, No. 4, June 1947; Herald of Health and Naturopath, October, 1947; November, 1947 (Published by T.J. Schippell, Wash., D.C.) in the editor’s column, “This Month with Dr. Schippell,” all have been parsed through to gather this history. This material is in the collected archives at the National University of Natural Health, Portland, Oregon. 87. Ibid. 88. Herald of Health and Naturopath, September, 1947 (Vol. 52, No. 9). Following Dr. Lust’s death in 1945 Dr. Schippell took over publication of this publication in the name of the (eastern) ANA, each monthly cover noting: “Founded in 1896 by Benedict Lust, Father of Naturopathy,” with the main editorials being “This Month with Dr. T.M. Schippell” and “Dr. Lust Speaking (reprints).” 89. “Outline of Curriculum for Schools and Colleges Teaching Naturopathy” by the ANA Committee on Education and Council on Schools and Colleges, adopted by the ANA House of delegates at the Annual meeting July, 1948 at Salt Lake City, and reported in Journal of the ANA, Inc., December-January, 1948-1949, pp. 11,21. 90. The first visit is reported in The Oregonian, Friday, December 3, 1947, and the second visit is reported in the Journal of the ANA, February, 1949, at p. 13; “National News Notes” report on the ONA’s convention in December 1948, also attended by a student delegation from Western States of 23 students, and further, in the Newsletter of the Washington State Naturopathic Association for February 1948, a copy of which is the John Bastyr Archive papers at Bastyr University. 91. Kelly v. O.G. Carroll, 36 Wn.2d 482, 219 P.2d 79 (1950). 92. Journal of the ANA, vol. 4, no. 6, June,1951, at p. 8 has an “In Memoriam” box noting Carroll’s passing on Friday, May 11, 1951; Obituary in Seattle Times, Sunday, May 13, 1951.

93. The primary tools for this analysis are the catalogs for the programs at WSC maintained in the UWS library archives and the textbooks referred to in these catalogs. The catalogs available will be referenced as the curriculum for each period is discussed. 94. Reference is to the catalogs in use in 1934–1937 and 1938–1939; UWS library archives. 95. UWS library archives. 96. Ibid. 97. Lake’s Treatment is described by Susan Cayleff at p. 38 of Nature’s Path: Naturopathic Healing in America (2016), Baltimore, Johns Hopkins Press, as presenting osteopathy, chiropractic, and naturopathy as a complementary set of skills necessary to a complete physician. 98. UWS library archives. 99. H. Riley Spitler, DC, ND, OD, of Eaton, Ohio was a pre-WWI graduate of Ross Chiropractic College of Fort Wayne, Indiana. Spitler was truly a renaissance man who deserves his own biography, and later in this series, he will get one. Among other things, he was a medical board examiner in neuropathy in Ohio for over 15 years; a member of the faculty of the Metropolitan Chiropractic College of Cleveland, Ohio, in mechanotherapy; and the originator of the syntonic principle that is still influential in optometry today. 100. UWS library archives. 101. The reference is to Rehm and Keating, as discussed previously. See IMCJ for February 2018, vol. 17, no. 1 at p. 20 102. Medford (OR) Mail-Tribune, Tuesday, June 10, 1930—front-page story reporting the newest census figures. 103. Medford (OR) Mail-Tribune, Sunday, April 4, 1943, references Hedges’s 32 years in practice in Medford and observing an annual “Health Week”; Wednesday, February 28, 1962, notes Hedges as receiving only the fourth “Lifetime Membership” in the Oregon Association of Chiropractic Physicians, having been in practice in Medford since 1911; the first of many regular ads for the Hedges practice that has been located in newspaper archives is in the edition for Wednesday, April 9, 1913. 104. Medford (OR) Mail-Tribune, Tuesday, March 4, 1930. 105. Ibid. 106. Lamm Lester. Oregon Pioneer: The Journey of Chiropractic Education in the Northwest. Portland, OR: University of Western States; 2014:22. 107. Amarillo Globe-Times, Tuesday, July 15, 1941. 108. Oakland Tribune, Thursday, December 18, 1941. 109. The Oregonian, Sunday, July 26, 1942, reported the election as VP; Friday, January 1, 1943, reported the Board appointment. 110. The Sunday, June 3, 1934, edition of The Oregonian had reported on the 25th Annual Meeting of the ONA, at which Budden spoke on the Ballot Campaign, and Hedges and Sargent and others participated in “a clinic demonstrating naturopathic procedures.” 111. (Salem) Statesman-Journal, Sunday, June 30, 1946; term effective July 2. 112. Medford Mail Tribune, Tuesday, November 29, 1949. 113. See “Editorial’ in Journal of the American Naturopathic Association, vol. 3, no. 11, November, 1950. 114. See “Editorial”. Journal of the American Naturopathic Association. June 1950;3(5). May 1950; see also “Editorial” in vol. 3, no. 6,. 115. Sunday, March 7, 1954, The Oregonian—meeting announcement for Friday, March 12, 1954. 116. Altschuler Glenn C, Blumin Stuart M. The GI Bill: A New Deal for Veterans. New York: Oxford Univ Press; 2009. 117. Oregon Pioneer, at p. 23. 118. A.E. Homewood at p. 30. 119. Martin Bleything’s background is discussed at length in a newspaper profile when he also graduated from Portland’s Lewis and Clark University with a BA in journalism in 1955—at age 65. The information about Grace University comes from materials in the John Bastyr Archives at Bastyr University. 120. Journal of the ANA, vol. 4, no. 6, June 1951. 121. There is a great deal of academic scholarship about these events, most extensively in Monte Poen’s Harry S. Truman Versus the Medical Lobby: The Genesis of Medicare (1979), Columbia, MO, University of Missouri Press. For capsule glimpses of the political power of the AMA, see Truman, David B. (1951; 2nd ed. 1971), New York, Alfred Knopf Publishing,

References pp. 170–177, 231–232. For the AMA battle with President Truman, see Hacker, Jacob S. (2002) The Divided Welfare State: The Battle over Public and Private Social Benefits in the United States, New York, Cambridge University Press, pp. 222–237. For a discussion of how these issues relate to the elements of medical dominance in U.S. healthcare policy, see Morone, James A. (1990; rev. ed. 1998), The Democratic Wish: Popular Participation and the Limits of American Government, revised edition New Haven, CT, Yale University Press 122. The AMA campaign that began in 1953 will be discussed more extensively later in the chapter. 123. Lamm Lester. Oregon Pioneer: The Journey of Chiropractic Education in the Northwest. Portland, OR: University of Western States; 2014. 124. This curriculum information comes from archived the college catalogs, officially called “Bulletin of the Western States College.” These are archived in the library collection in the W. A. Budden Library at the University of Western States. For this section, these Bulletins have been referenced: Volume No. XXV, June 1949, Annual Catalog Schools of Chiropractic and Naturopathy for 1949–1950; Volume No. XXVI, June 1950; Annual Catalog Schools of Chiropractic and Naturopathy for 1950–1951; Volume No. XXVII, March 1951, Annual Catalog Schools of Chiropractic and Naturopathy for 1951–1952; No. XXVII (2), March 1951; Annual Catalog School of Naturopathy for 1951–1952; No. XXVIII, May 1952, Annual Catalog Schools of Chiropractic and Naturopathy for 1952–1953. 125. The Synergist was the monthly “Voice of the Student Body” of the time. As vol. 4, no. 7 was April 1953 as the class of 1953 was graduating, this monthly looks like publication was begun as the class arrived in fall 1949. These sketches of campus life come from the several volumes archived at UWS. 126. See previous references to Dr. Schlichting’s speeches on the state of naturopathy, circa 1952. 127. The Oregonian, Saturday, March 7, 1953. 128. The Oregonian, Wednesday, March 11, 1953. 129. The convention news itself was in The Oregonian, Friday, July 17, 1953, with lengthy interview coverage of the convention appearance by soils and food sciences professor from the University of Missouri, Dr. William Albracht. 130. Ibid. 131. An obituary in The Oregonian, Wednesday, August 18, 1954, notes his death on August 1. The circumstances are described in Oregon Pioneer, at p. 27. 132. Oregon Pioneer, pp. 33-34. 133. Nature Doctors, by Kirchfeld and Boyle at pp. 297–302 covers the career in naturopathy of Joe Boucher. 134. Oregon Pioneer, see especially 104–105. 135. Nature Doctors p. 310; more discussion of this later in the chapter. 136. Ibid. 137. Journal of the ANPSA, September, 1952 (volume 6, number 6). 138. The National Chiropractic Journal, September, 1939 (Vol. 8, No. 9). 139. El Paso Herald-Post, Monday, April 8, 1957; Amarillo Globe-Times (TX), Monday, May 09, 1938; Amarillo Sunday News and Globe, Sunday, August 14, 1938; Midland Reporter-Telegram, Wednesday, November 26, 1941 and Monday, November 24, 1941 and Monday, January 12, 1942. 140. Various issues of the Midland Reporter-Telegram from 1941–1944 carried ads for Dr. Schlichting’s practice “emphasizing fractures and dislocations”; the Carver technique is discussed in Wardwell, Walter (1992) Chiropractic: History and Evolution of a New Profession (St. Louis, Mosby, Inc.). 141. Midland Reporter-Telegram, Monday, November 24, 1941. 142. See previous column re: ANA convention of 1942 and The Canyon (TX) News, Thursday, November 2 and Thursday, November 9, 1944, and Thursday, October 25, 1945 re: H. A. Brown, ND. 143. See Note 132. 144. Walter Wardwell. Chiropractic: History and Evolution of a New Profession. St. Louis: Mosby, Inc; 1992. 145. Ibid, p. 89. 146. Johnson, Alton Cornelius (1939), Principles and Practice of Drugless Therapeutics (Los Angeles, Chiropractic Educational Extension Bureau); see previous column on Western States’ postwar curriculum; see Journal of the ANA and ANPSA 1948–1954, especially Journal of the ANA September 1948 (vol. 1, no. 9) at page 18 for Johnson’s initial column on physiotherapy and his explanation of being recruited for and acceptance of his position.

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147. See previous columns and specifically: Naturopath and Herald of Health, July 1942; August 1942; January 1943; Newsletter from the American Naturopathic Association, Office of the Secretary, Midland, Texas, dated March 1, 1947, listing Robert A. Carroll as president; American Naturopath, vo. III, no. 4, June 1947; Herald of Health and Naturopath, October, 1947; November, 1947 (Published by T. J. Schippell, Washington, D.C.) in the editor’s column, “This Month with Dr. Schippell”; all have been parsed through to gather this history. This material is in the collected archives at the National University of Natural Health, Portland, Oregon. 148. Ibid. The constitution and bylaws adopted in 1935 were printed and published in Naturopath and Herald of Health, November 1935 and January 1936; Naturopath and Herald of Health, November 1941; January 1942. 149. See also Journal of the ANA, April 1948 (vol. 1, no. 4); August 1948 (vol. 1, no. 8); and September 1948 (vol. 1, no. 9). 150. Wardwell Walter. Chiropractic: History and Evolution of a New Profession. St. Louis: Mosby, Inc; 1992; Keating Joseph C Jr, Callender Alana K, Cleveland Carl S III. A History of Chiropractic Education in North America. Scottsdale, AZ: Council on Chiropractic Education; 1998. 151. Fort Wayne (IN) News and Sentinel, July 23, 1918; Keating et al. (note xiii); John Bastyr’s diploma and other information are in archives or on display at Bastyr University; for the story of mixers licensed as NDs in “straight” states such as Utah and South Carolina, see Phillips, Reed B. (2006) Joseph Janse: The Apostle of Chiropractic Education (Reed Phillips, publisher). 152. See El Paso Herald-Post, Monday, April 8, 1957. 153. Journal of the ANA July, 1949 (vol. 2, no. 7). 154. Journal of the ANA July, 1949 (vol. 2, no. 7). 155. Keating Joseph Jr C, Callender Alana K, Cleveland Carl III S. A History of Chiropractic Education in North America (Scottsdale, AZ. Council on Chiropractic Education; 1998. 156. Journal of the ANA June, 1951 (Vol. 4, No.6)—W. Martin Bleything, Editor. 157. Journal of the ANA June, 1951 (Vol. 4, No.6)—W. Martin Bleything, Editor. 158. Journal of the ANA June, 1951 (Vol. 4, No.6); Reno Evening Gazette, March 6, 7, 15, 1951; The Atlanta Constitution, February, 17, 1950; Keating, Joseph C., Jr., Callender, Alana K., and Cleveland, Carl S. III (1998) A History of Chiropractic Education in North America, (Scottsdale, AZ, Council on Chiropractic Education). 159. Attorney general’s Opinion Letter V-1486, July 29, 1952, to Henry J. Schlichting, ND, Secretary, Texas Board of Naturopathic Examiners; Journal of the ANA, September 1948, for Dr. Spitler’s remarks on Tennessee. 160. The Connecticut story told here is taken from coverage by The Hartford Courant for the following dates: June 6, August 20, 1946; March 20, April 24, May 7 and 29, July 16, 1947; and January 22 and 23, 1948. 161. The South Carolina story is taken from the coverage of the Charleston (SC) News and Courier for June 27, 1946; April 24, May 14 and 28, November 15, 1947; and April 11, 1949. 162. AG Opinion Letter V-1486, July 29, 1952, to Henry J. Schlichting, ND, Secretary, Texas Board of Naturopathic Examiners. 163. Journal of the ANA August, 1951; Journal of the ANPSA October and November, 1951. 164. Journal of ANPSA, September, 1951. 165. Proceedings of the House of Delegates. American Medical Association Annual Meeting; 1953. 166. Poen Monte M, Harry S. Truman Versus the Medical Lobby. Columbia, MO, Preface: University of Missouri Press; 1979. 167. (2013) (The Johns Hopkins University Press, Baltimore). 168. Volume 71, Issue 3, July 1, 2016. 169. AG Opinion Letter V-1486, July 29, 1952, to Henry J. Schlichting, ND, Secretary, Texas Board of Naturopathic Examiners. 170. See AG Opinion Letter S-60, to Austin F. Anderson, Criminal District Attorney, June 29, 1953, “Re: Constitutionality of Article 4590d, V.C.S. relating to the practice of naturopathy.” 171. See Sabota, Leo M. and Martin, J. David “The Texas Attorney General-An Alternate State Supreme Court,” in Kraemer, Carin and Maxwell (1975) Understanding Texas Politics (West Publishing Co., St. Paul, MN). 172. Committee Report to 1948 Convention of the ANA, Salt Lake City, UT, June, 1948, as reported in Journal of the ANA for September, 1948.

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References

173. Kuts-Cheraux AW. Naturae Medicina and Naturopathic Dispensatory. American Naturopathic Physicians & Surgeons Assn., Des Moines, IA. Chattanooga, TN: Lulu Enterprises, Inc; 1953. Reprint (2007). 174. Altschuler Glenn C, Blumin Stuart M. The GI Bill: A New Deal for Veterans. New York: Oxford Univ. Press; 2009. 175. Keating Joseph Jr C, Callender Alana K, Cleveland Carl III S. A History of Chiropractic Education in North America. Scottsdale, AZ: Published by Council on Chiropractic Education; 1998. 176. Commencement announcement—UWS Archives. 177. See Pittsburgh Press, Sunday, June 27, 1954, for extensive coverage of the Hoxsey cancer treatment events in Pennsylvania in the summer of 1954. Hoxsey had been battling the U.S. government since 1950 in Texas, but it was only in 1953 and 1954 that he began being described as a “naturopath.” See Dallas Morning News, Tuesday, June 30, 1953; for more on Hoxsey’s entire career, which began in his native Iowa in the 1930s, see The Los Angeles Times, September 29, 1988, review of the documentary Hoxsey: Quacks Who Cure Cancer. 178. Abilene Reporter-News, February 8, 1955; The Cameron (TX) Herald, February 17, 1955; The Corpus Christi (TX) Caller-Times, February 3, 1955. 179. The history of WSC after Dr. Budden’s death through the discontinuance of the School of Naturopathy is taken from Oregon Pioneer, pp. 31–35; A History of Chiropractic Education in North America, pp. 361–372, especially; and correspondence between Dr. Ralph Failor and Dr. Higgens and associated records from Dr. Failor’s tenure found in the UWS library archives. 180. The Austin (TX) American, January 25, 1956; March 28, 1956; Austin (TX) American-Statesman, May 25, 1956. 181. There were over 1000 news stories statewide in Texas in 1957 reporting the Texas naturopaths’ saga. This telling here draws from all of them, but specifically from the coverage by The Austin (TX) American for these dates: February 27, March 1, 4, 5, 8, 10, 13, 17, 19, 24, 28, April 3, 8, 12, 21, 24, May 2, 3, 8, 9, 10, 15, 23, 31, July 1, 7, 9, 13, 15, 25, 26, August 1, October 6, 8, 11, 12, 14, 21; and the Austin (TX) American-Statesman for February 28, March 4, 7, 12, 15, 20, 28, April 1, 3, 19, 27, May 6, 8, 31, July 1, 3, 8, 13, 25, October 2, 16. Also The Odessa (TX) American for April 19, 1957, about the “mystery witness.” 182. Valley Morning Star (Harlingen, TX), January 31, 1957 (Associated Press).

183. El Paso Herald-Post May 1 and May 3, 1957; C.I. Douglas, Reporter. 184. Ibid. 185. Austin American December 3, 9, 23, 24, 29; Austin American-Statesman 12/ 2. 186. Ibid. 187. Austin American January, 23, February 20, March 26; Austin American-Statesman February 19, 1958. 188. Big Spring Herald (TX) January 22, 1961; Midland Reporter-Telegram (TX) April 30, 1962; Arizona Republic September 7, 1965; Arizona Republic, June 5, 1973; Lubbock Avalanche-Journal, June 6, 1973. 189. The Miami Herald April 19, April 20, 1949. 190. The State, Columbia, SC, March 17, 1955. 191. The Miami Herald April 19, 20, 1949. 192. The Miami Herald, April 20, 1949. 193. Lawrence Thompson, Reporter, The Miami Herald. 194. Charleston News and Courier, May 1, 1955. 195. Miami Daily News, Jane wood, Reporter, November 23, 24, December 1, 2, 1955 196. Miami Daily News, April 4, 1957. 197. Salt Lake Telegram, March 24, 1925; Salt City Telegram, March 5, 1937; The Salt Lake Tribune, February 16, 1939; Salt Lake Telegram, legislative coverage February of each legislative session, 1941, 1943, 1945. 198. Salt Lake Tribune, September 20, 1946. 199. The Ogden (UT) Standard-Examiner, September 3, 1955. 200. The Daily Herald (Provo, Utah), June 19, 1956; August 9, 1956; December 21, 1956. 201. The Ogden Standard-Examiner (Ogden, UT), March 22, 1957. 202. Salt Lake City Tribune, January 29, 1959; The Ogden Standard-Examiner (Ogden, UT), March 25, 1959; The Salt Lake Tribune, November 2, 1961. 203. State v. Houck, 32 Wn. (2d) 681,203 P. (2d) 693 (1949); Kelly v. Carroll, 36 Wn.2d 482, 219 P.2d 79 (1950); State v. Kelsey, 46 Wn.2d 617, 283 P.2d 982 (1955). 204. Independent Practitioners Under Medicare: A Report to the Congress. U.S. Department of Health, Education and Welfare, William J. Cohen, Secretary, Naturopathy; 1968:126–145. 205. Ibid at page 137.

5 Philosophy of Naturopathic Medicine Rachelle S. Bradley, ND

OUTLINE Introduction, 80 Medical Philosophy, 80 Vitalism Versus Mechanism, 80 Vitalism, 81 Meaning of Disease, 83 Scientific Medicine, 84

INTRODUCTION This chapter examines the philosophical foundation of naturopathic medicine and its modern applications. Unlike most other health care systems, naturopathy is not identified by any particular therapy or modalities (e.g., conventional medicine, drugs and surgery; chiropractic, spinal manipulation). A wide variety of therapeutic styles and modalities are found within the naturopathic community (Box 5.1). For example, there are still practitioners who adhere to the strict “nature cure” tradition and focus only on diet, “detoxification,” lifestyle modification, and hydrotherapy. There are also those who specialize in homeopathy, acupuncture, or natural childbirth. At the other end of the spectrum are naturopathic physicians who use botanical medicines, nutraceuticals, and pharmacology extensively to manipulate the body’s biochemistry and physiology. Finally, there is the majority, who practice an eclectic naturopathic practice that includes a little of everything. Since its inception 130 years ago, naturopathic medicine has been an eclectic system of health care. This characteristic has allowed it to adopt many of the more effective elements of natural and alternative medicine and to adopt conventional medicine’s basic and clinical sciences, diagnostics, and pharmacology. Through all of this eclecticism, naturopathic medicine has always identified the Latin expression vis medicatrix naturae (the healing power of nature) as its philosophical linchpin. However, the expression vis medicatrix naturae, by itself, does not provide a clear picture of naturopathic medical philosophy or an understanding of the practice of naturopathic medicine in all of its varied forms. With the profession’s history of eclecticism, no two practitioners treat any individual patient exactly alike. This situation has its advantages (e.g., individualization of each patient’s care, more therapeutic options) but also makes it difficult to perceive the profession’s philosophical cohesiveness. Another major disadvantage of this eclecticism is the difficulty in developing consistent practice standards. To attempt to solve this problem, the modern profession has articulated a general statement of naturopathic principles that expand on

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Naturopathic Philosophy, 84 Vis Medicatrix Naturae, 84 Natural Medicines and Therapies, 85 Family and Specialty Practice, 85 The Philosophical Continuum, 86 Conclusion, 86

vis medicatrix naturae (Box 5.2). However, to gain a more in-depth understanding of naturopathic medicine, one must discuss medical philosophy in general. 

MEDICAL PHILOSOPHY The issues fundamental to a discussion of medical philosophy have changed little since naturopathy first appeared as a distinct profession at the end of the 19th century. What has changed is the level of understanding of the biological process and the language of science. Most people who study the early writers on naturopathic medical philosophy quickly get lost in the archaic language and arguments used to justify the theories. This chapter translates these concepts and issues into modern terms.

Vitalism Versus Mechanism Historically, there have been two main medical philosophies, those of vitalism and mechanism. Their origins can be traced to the Hippocratic writings of ancient Greece. Throughout history, the line separating these two schools of thought has not always been clear, but their philosophical perspectives have generally been in opposition. The conflicting goals and philosophical foundations of these two concepts remain relevant as the modern practices of conventional and alternative physicians come into conflict. As will be seen, the foundations of naturopathic medical philosophy are found in vitalism. However, naturopathy also recognizes the practical value of the mechanistic approach to health care.

Mechanism Up to the early part of the 20th century, there was considerable debate over the issue of vitalism versus mechanism in the field of biology. The mechanists, or materialists, maintained that the phenomenon of life could be explained exclusively as the product of a complex series of chemical and physical reactions. They denied the possibility that the animate had any special quality that distinguished it from the

CHAPTER 5 

BOX 5.1  Naturopathic Modalities Naturopathic physicians are trained to use a number of diagnostic and treatment techniques. These modalities include the following: • Diagnosis. All the conventional clinical laboratory, physical diagnosis, and imaging (e.g., radiography) techniques, as well as holistic evaluation techniques • Counseling. Lifestyle, nutritional, and psychological • Natural medicines. Nutraceuticals (i.e., all food constituents, constituents of biochemical pathways, etc.), botanical medicine, and homeopathy • Physical medicine. Hydrotherapy, naturopathic manipulative therapy, physiotherapy modalities, exercise therapy, and acupuncture • Family practice. Natural childbirth, minor surgery, natural hormones, biologicals, and pharmaceuticals

BOX 5.2  The Principles of Naturopathic

Medicine

The Healing Power of Nature: Vis Medicatrix Naturae Nature acts powerfully through healing mechanisms in the body and mind to maintain and restore health. Naturopathic physicians work to restore and support these inherent healing systems when they have broken down by using methods, medicines, and techniques that are in harmony with natural processes.  First Do No Harm: Primum Non Nocere Naturopathic physicians prefer noninvasive treatments that minimize the risks of harmful side effects. They are trained to know which patients they can treat safely and which ones they must refer to other health care practitioners.  Find the Cause: Tolle Causam Every illness has an underlying cause, often in aspects of the lifestyle, diet, or habits of the individual. A naturopathic physician is trained to find and remove the underlying cause of a disease.  Doctor as Teacher: Docere A principal objective of naturopathic medicine is to educate the patient and emphasize self-responsibility for health. Naturopathic physicians also recognize and employ the therapeutic potential of the doctor–patient relationship.  Treat the Whole Person Health or disease comes from a complex interaction of physical, emotional, dietary, genetic, environmental, lifestyle, and other factors. Naturopathic physicians treat the whole person, taking all of these factors into account.  Preventive Medicine The naturopathic approach to health care can prevent minor illnesses from developing into more serious or chronic degenerative diseases. Patients are taught the principles with which to live a healthy life; by following these principles they can prevent major illnesses.

inanimate. It was their contention that the only difference between life and nonlife was the degree of complexity of the system. Mechanism has several other distinctive characteristics. Its most obvious is that it is reductionistic. Reductionism is often used as a synonym for mechanism. Mechanistic science is also characterized by an emphasis on linear causality. Without this emphasis on reductionism and linear causality, Western science and medicine would probably have not been so successful. As the 20th century advanced, each new discovery in biological and medical science reinforced the arguments for mechanism, until, by the middle of the century, the biology community had almost exclusively embraced the philosophy of mechanism.

Philosophy of Naturopathic Medicine

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Mechanism is the philosophical foundation of biomedical science and conventional medicine. It is especially visible in the treatment modalities of surgery and most pharmaceuticals. Mechanistic medicine identifies disease and its accompanying signs and symptoms as simply the result of a disruption of normal chemical reactions and physical activities. Such disruptions are caused by the direct interference in these reactions and activities of a “pathogenic agent.” (For the purposes of this discussion, the expression “pathogenic agent” refers to any known or unknown etiological agent, influence, or condition; examples are microbial agents, autotoxins, genetic defects, environmental toxins, non–end-product metabolites, and physical and emotional stress and trauma.) A living organism, then, is simply a very complex machine that, as a result of external agents and influences and “wear and tear,” breaks down. Because the signs and symptoms of disease are thought to be caused only by these mechanical disruptions and interference with reactions, they are considered to be completely destructive phenomena and are therefore to be eliminated. Disappearance of the signs and symptoms indicates that the pathogenic agent and its resulting disease have been eradicated or, more likely, controlled. The goals of mechanistic medicine tend to be the quick removal of the signs, symptoms, and pathogenic agent. Mechanistic medicine is being practiced in cases in which the intention of the therapy is to intervene in the perceived mechanism of the disease and/or to relieve the symptoms. Examples would be the use of antihistamines to relieve rhinitis, vitamin B6 to help carpal tunnel syndrome, emergency care for traumatic injuries, coronary bypass surgery for blocked arteries, and insulin in juvenile-onset diabetes. Mechanism is also being used when an identified pathogenic agent is directly attacked or eliminated; for example, the use of antibiotics or the isolation of a patient from a particular allergen. Clearly, mechanistic medicine can be very effective in achieving its goals. In the presence of modern medical technology, it is easy to see how this philosophy came to dominate biology, medicine, and the attention of the public. However, the unsolved problems of mechanistic medicine—particularly those of chronic degenerative disease; authoritarianism, which alienates patients from responsibility for their own health; and the rising cost of health care—suggest that there are limits to the mechanistic perspective and explain why vitalism has not disappeared and is in resurgence. 

Vitalism The philosophy of vitalism is based on the concept that life is too well organized to be explained simply as a complex assemblage of chemical and physical reactions (i.e., a living system is more than just the sum of its parts). This is in contrast to the mechanist’s contention that “the only difference between life and non-life is the degree of complexity.” Throughout the 19th century, the debate between vitalism and mechanism was carried out mostly by biologists and, in medicine, between the “regular” doctors and those doctors who would now be called alternative. In the medicine of the 19th and early 20th centuries these would have been homeopathic, hydrotherapy, nature cure, and eclectic doctors—all medical doctors with equivalent credentials under the laws of the time. Although the specific terms of “vitalism” and “mechanism” were not necessarily the nomenclature of their debate, the perspectives were the same. Interestingly, through most of the 19th century this debate within the medical community was distinctively not based on science as we currently think of it. The “regular” doctors of the era, as represented by the American Medical Association, were still strongly influenced by Galen’s theory of disease of the four humors with its imaginary anatomy and physiology, bleeding, leeches, mercury, and other horrific treatments. Both the homeopaths and eclectic doctors argued based on

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Philosophy of Natural Medicine

empirical evidence; on the other side, the regular doctors argued based on a dogmatic theory that was more than 1500 years old and unsupported by any evidence. Harris Coulter produced the seminal work on this debate in his three-volume book, The Divided Legacy. The debate between vitalism and mechanism within the field of biology is well documented within the biology journals of the time. This was an era of amazing discoveries about how life functioned. Naturally, this is where the focus of this debate took place for biologists. As the secrets of cellular metabolism were revealed, this debate lurched from one specific argument to the next. The issue was where in the living organism did “God” have direct control. For example, at one point it was argued that the “seat of the soul” was the cell. As the cell was better understood, the place that was the point of God’s intervention was postulated to be the nucleus. As research further revealed how the organelles functioned, the vitalistic biologists gave up ground until vitalism as a distinct philosophy in biology was finally abandoned. The error that doomed the vitalistic-oriented biologists was that they were all reductionistic in the same way as the mechanistic biologists. Reductionistic science seems completely able to learn how life functions from a biochemical and biophysical perspective. Eventually, all of the individual chemical and physical reactions that are found in the processes of life will probably be identified. However, the vitalistic biologists missed the most essential aspect of vitalism: holism. In naturopathy’s early years there were few interactions between it and the academic and research worlds. The great authors and practitioners came to naturopathy through “conversion,” in other words, most had been cured of some health problem by a natural cure and felt naturopathy and curing the sick was now their calling. There is no evidence that these naturopaths even knew that this debate between vitalism and mechanism was going on in the biology literature. Research in this early era of naturopathy consisted of observing nature and applying these observations to treating patients. This led to a deep appreciation of “nature’s” desire for balance and order (what a physiologist would call homeostasis). This holistic perspective, combined with the results of the naturopathic treatments, was the empirical evidence that drove their understanding of health and disease. It was only in the latter half of the 20th century that the field of naturopathic medicine began to converge with the academic and research worlds. Since the 1970s this convergence has moved at breakneck speed, until today there is no longer any real distinction (although this is not evident in some of the politically motivated diatribes against the field of natural medicine). However, by this time the academic and research worlds had long since forgotten about vitalism. An organism’s unique complexity—as demonstrated by its ability to grow and develop, respond to stimuli, reproduce, and repair itself—requires a level of organization and coordination that suggests a distinct quality that is not readily explained by mechanism. This is studied extensively by all medical students in physiology class as the “normal” homeostatic process common to all living organisms. However, the tendency in conventional medical school is to put the concept aside when the student moves on to study pathology and the clinical sciences. Yet up to the point of death, maintaining homeostasis is a prime, if not the primary, driving force in all living organisms. To think that homeostasis is only an important factor in “normal” physiological processes and has no relevance in pathology is to ignore all of the basic sciences. All life is attempting to return to this ideal state whenever injured or ill. The only point in the life cycle that an organism is no longer “trying” to maintain homeostasis is death. Reductionistic science has done a wonderful job elucidating the functions of the various components of life, but it tends to focus the researcher and the physician on the disease process as an isolated phenomenon rather than the result of a complex reaction of the whole

organism to a pathological agent. Fortunately, the debate between the vitalistic and mechanistic perspectives in the modern era focuses on the more relevant and holistic general concepts. Although modern vitalism is inherently holistic in its view, there is no conflict with the findings of biomedical science. What is significant is not the individual biochemical or biophysical reactions, but the fact that they are all coordinated to such a degree as to produce the special activities of a living organism. Because there is no inanimate counterpart to this level of complexity and organization, homeostasis is the most dramatic general argument in favor of vitalism. A less dramatic argument supporting the vitalistic perspective is the “problem of entropy.” Entropy is the tendency of any closed system to find equilibrium, that is, the state of least organization. In other words, systems tend to run down and become less complex over time. In defiance of this universal rule, life, up until the point of death, consistently creates more complex systems out of simple ones. To do this, life actively pursues external matter and energy to incorporate into itself while also selectively eliminating byproducts from its use of this matter and energy. When the problem of entropy is examined on the molecular level, the same individual chemical processes and elements may be found in both animate and inanimate systems. In the inanimate system, however, there is a constant move toward a state of chemical equilibrium. This type of system cannot maintain an unstable chemical state and always seeks stabilization. Even after the addition of external exciting energy, the system returns to the simplest, least reactive state possible. The animate system is virtually the opposite. It is continuously in a state of dynamic chemical instability, actively seeking energy to maintain this instability and consistently moving to more complex and more organized states (and back again). It is only at the onset of death that an animate system begins to move toward equilibrium, and, of course, then it is no longer animate. The third general argument in favor of a vitalistic view of life is evolution. For evolution to exist as a force in nature, generations of living organisms have to survive long enough to grow, reproduce, and then evolve. For this survival to take place, the organisms’ homeostatic and repair processes must be consistently directed toward maintaining a state of balance with the external environment (i.e., health). Any organism that does not behave biochemically and physiologically in this manner dies and cannot evolve. Thus the phenomenon of evolution, as the action of countless living organisms over eons, multiplies life’s antientropic quality and is incompatible with a mechanistic view of living systems. These easily observable examples of life’s “special quality” suggest an “organizing force” that goes beyond what is possible from mere chemistry. This quality that makes life unique should not be mistaken as a metaphysical concept, although an argument for or against such concepts is not intended here. The point is only that vitalism is a medical philosophy based on observable scientific phenomena. Unfortunately, a definitive definition of this quality (in the old literature called the “vital force,” defense mechanism, or simply “Nature”) will have to wait for vitalistically or holistically oriented researchers. Reductionistic research has not provided much clarification of these special qualities of life—just ask a modern reductionistic biologist to explain how homeostasis works. They can describe what happens on a biochemical and biophysical level, but they cannot describe why it happens. At this point in the discussion, not many mechanistic practitioners would have reason to be uncomfortable. However, the conflict becomes evident with examination of the premises on which the practice of vitalistic medicine is based. What truly separates vitalism from mechanism and makes it useful as a medical philosophy is its perspective on disease and its associated symptoms. 

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BOX 5.3  Cure, Suppression, Palliation, and Healing Cure: A cure occurs when: (a) a treatment is given to the person; (b) the signs and symptoms of the disease go away; (c) the treatment is removed and the signs and symptoms stay away; and (d) the whole person is healthier and less likely to get sick than before the illness. This is almost always going to occur only when the whole person was treated, and not just the disease or its symptoms. Palliation and suppression never lead to cure in and of themselves. Palliation: Palliation occurs when: (a) a treatment is given for the disease; (b) the signs and symptoms of the disease go away; but (c) when the treatment is removed the signs and symptoms return. The symptoms of the disease are simply being controlled (not cured) as long as the treatment is continued. It is a classic error of many practitioners and patients to equate palliation with moving toward cure. Palliation is on the opposite end of the spectrum as cure and is closer to suppression. Palliation can be useful but, in and of itself, never leads to cure—other more vitalistic and holistic interventions are necessary and may be as simple as changing to a healthier diet, removing some obstacle to recovery, or reducing stress, or as complex as classical homeopathy or traditional Chinese medicine. When palliation is used over a long enough time, suppression is the natural consequence. Palliation is the most common result of almost all health care interventions. This is especially true of conventional medicine but also true for much of alternative medicine as well. Unfortunately, both the practitioner and the patient’s expectations are frequently satisfied with palliation. This is the most frustrating aspect of modern health care, whether conventional or alternative. Too few people are striving for a cure.

Meaning of Disease Vitalism maintains that the pathogenic agent does not directly cause most symptoms accompanying disease; rather, they are the result of the organism’s intrinsic response or reaction to the agent and the organism’s attempt to defend and heal itself. Symptoms, then, are part of a constructive phenomenon that is the best “choice” the organism can make, given the circumstances at any particular time. Symptoms can be further described as arising from two situations. The first and most common situation is when the symptoms are from what would traditionally be called a “healing reaction”—the organism’s concerted and organized attempt to defend and heal itself (i.e., the organism’s homeostatic process). These healing reactions produce what can be called “homeostatic symptoms.” Examples are fever and inflammation in infections, almost any reaction of the immune system, and many of the symptoms of chronic disease. This interpretation of symptoms is generally ignored by mechanism. Instead, it views a symptom as the result of a destructive process and focuses on intervening by relieving the symptom or manipulating the pathological mechanism. Mechanistic medicine is therefore most often working contrary to homeostasis and the organism’s attempt at healing (this is usually its intent). When this therapeutic approach is effective, vitalists call the result a “suppression” (Box 5.3). This approach to health care is so pervasive that most people, lay and professional alike, still think nothing of suppressing mild fevers with antipyretics. In contrast, vitalism considers these homeostatic symptoms to be the product of a constructive phenomenon and therapeutically stimulates and encourages this directed healing process. In contrast, vitalism considers these symptoms to be the product of a constructive phenomenon and therapeutically stimulates and encourages this directed healing process. Rather than simply trying to

Suppression: Suppression is when: (a) a treatment is given for a disease; (b) the signs and symptoms of the disease go away; (c) the treatment is removed and the signs and symptoms stay away; but (d) the whole person is less healthy. Although the symptoms of concern are better, the whole person is worse, which leads to more and worse disease in the future. In conventional medicine suppression is often a goal. Alternative medicine tries for a higher standard, but because palliation is often what happens, suppression can occur here, too. Suppression frequently occurs because a treatment is given for a symptom or disease rather than the whole person being treated. Suppression may lead later to another more invasive illness. Healing: Healing is what a living organism (body–mind) does, or attempts to do, for itself. A treatment can only: (a) control signs and symptoms (palliate or suppress); (b) support life in a crisis (palliate or suppress); (c) attack an invading organism such as bacteria or remove a pathological agent such as a toxin or allergen (palliate); (d) mechanically repair tissues that have been damaged or are malformed (palliate); or (e) support and/or stimulate the organism’s innate healing processes while the body–mind does the work of healing itself (cure). Curative treatment involves stimulating the whole organism to heal itself. The palliation and suppression of symptoms does not help stimulate self-healing. Palliation tends to create the opposite effect and suppression actually gets in the way of the whole body–mind’s efforts to self-heal.

eliminate a pathogenic agent, as mechanistic therapy might, vitalism focuses more on augmenting the organism’s resistance to that agent. That is not to say that vitalists object to removing the agent, only that it should be done in the context of simultaneously increasing resistance (in other words, decreasing susceptibility). The importance of this approach becomes evident when one recognizes that disease is only possible when both a pathogenic agent and a susceptibility to that agent are present. Healing reactions can take several forms. In the first type, an organism’s response to a pathogenic agent does not produce symptoms. When the organism is capable of easily defending itself from the agent, no symptoms are perceivable. This is a common homeostatic process and is demonstrated when a potential pathogen, such as β-hemolytic streptococcus, is cultured from a healthy person’s throat. However, when the organism is more susceptible or the relative strength of the pathogenic agent is greater, a threshold is reached and symptoms become perceivable. Successful healing reactions of this type include vigorous acute diseases that quickly resolve. The early naturopaths would have called these acute reactions “healing crises.” As the susceptibility of the organism increases relative to the strength of the pathogenic agent, there is a greater likelihood that the healing attempt will not be successful. When such a reaction is unsuccessful but vigorous, death may result, unless there is timely application of vitalistic or mechanistic therapy. Examples of this situation are acute bacterial meningitis and cholera. When the healing attempt is feeble and therefore ineffective, the reaction usually goes into the “chronic disease” stage. Vitalists observe that suppression seems to increase the likelihood that the reaction will be forced to go into such a chronic stage. In this situation the reaction is “smoldering,” and most often the organism cannot overcome the

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pathogenic agent unassisted. It just “holds its own,” and as the organism’s general health decreases over the years, the reaction gradually degenerates, producing symptoms that become less homeostatic as it moves to an end-stage pathology. Palliating the symptoms during this phase of the disease contributes to the declining health over time because palliation means that the underlying susceptibility or problem is not being addressed in a curative manner. If the organism can be therapeutically stimulated to produce a more vigorous healing reaction, it can often successfully complete the original healing attempt. This augmented reaction is another example of a naturopathic healing crisis and would also be called an “aggravation” by the vitalists who practice homeopathic medicine. Intervening mechanistically by relieving symptoms does little to stimulate or encourage the healing response; it usually actually inhibits the healing response. In contrast, vitalistic therapies can be very effective in helping these healing reactions, because the goals of such therapies are precisely the same as those of the organism. Thus it is thought that vitalistic medicine works because, by honoring this process and thereby strengthening the whole organism, it encourages a more effective healing effort. Ideally, the organism is then able to accelerate and complete its reaction against the pathogenic agent, leading to the permanent disappearance of the symptoms as it returns to a state of health. It would be naive to say that every stage of the healing reaction is positive and in the best interest of the organism or that no symptoms should be palliated. The modern vitalist acknowledges that palliative intervention is sometimes necessary. In contrast, it is important to note that routine mechanistic intervention can encourage its own worstcase scenarios. When mechanistic therapies successfully suppress an organism’s chosen healing reaction, a less effective and less desirable response is often produced. Therefore when suppression occurs, it can lead to a more complicated medical situation. Consequently, the very practice of mechanistic medicine tends to reinforce its practitioner’s conviction that such intervention is usually necessary. It should be noted, however, that not all mechanistic intervention leads to suppression. It happens less often when the pathogenic agent can be readily eliminated, such as the use of an antibiotic in nonrecurring acute bacterial infections, or when relatively noninvasive therapies are used, such as natural medicines. The second type of symptom-producing situation occurs when the organism produces symptoms in response to an organic lesion that arises from the direct pathological influence of a pathogenic agent. These could be called “morbid symptoms,” examples of which are symptoms from the mass of an invasive tumor, shortness of breath from emphysema, and pain of an injury or myocardial infarction. It should be mentioned that even these symptoms are the result of the organism’s overall effort to maintain homeostasis, and homeostatic symptoms are also often present. In addition, a morbid symptom is not necessarily without utility. For instance, pain is valuable as an indication of tissue damage. As can be seen, many, if not most, of these situations involve end-stage disease. Here mechanistic therapies can be very positive when the goals of the therapy do not conflict with those of the organism. There are instances when invasive mechanistic intervention will probably be required to save “life and limb.” These include such conditions as birth and genetic defects, serious traumatic injuries, crisis situations, overwhelming infections, and many malignancies. Unfortunately, mechanistic intervention does not guarantee a successful outcome either. Even in these situations, however, the effectiveness of vitalistic and natural therapy should not be underestimated, and their concurrent use will certainly augment any mechanistic intervention.

The concept of homeostatic and morbid symptoms can be a useful tool to help the understanding of the healing and disease processes, but in many situations it may not be possible to categorize the type of symptoms produced. A rough rule of thumb, however, would be that virtually all symptoms accompanying reversible or functional diseases are homeostatic. In contrast, many of the symptoms associated with traumatic injury and end-stage pathology would be morbid symptoms. 

Scientific Medicine Although mechanism and vitalism represent opposing perspectives, the systems of medicine that represent these philosophies can be successfully tested and examined with the scientific method.1 That is not to say that the philosophy of vitalism has been unquestionably proven—only that the validity of vitalistic interventions can be scientifically demonstrated. If a therapy can be proven effective, the effectiveness implies the accuracy of the philosophy on which it is based. Unfortunately, very few of the vast resources of the biomedical community have been directed toward investigating vitalistic medicine. Conventional medicine, as the dominant health care system and a representative of mechanism, has claimed for itself the title “scientific medicine.” However, it is inherently no more or less scientific than vitalistic medicine. A system is scientific only when it has met the criteria of the scientific method. This method requires the collection of data through observation and experimentation and the formulation and testing of hypotheses. Nonprejudicial science can effectively study any system, but the researcher must understand the system’s particular paradigm. Experiments on a vitalistic therapy based on a reductionistic and mechanistic model are not going to be constructed to show success, or if they do show success, it will be entirely fortuitous. The criteria of the scientific method can be met by vitalistic medicine, but only when the researchers recognize that it cannot be studied as though it is reductionistic or based on a simplistic model of linear causality. When the experimental model acknowledges the complexity of a living system in a social context (i.e., holism and circular causality/feedback loops), vitalistic medicine proves to be both verifiable and reproducible and, thus, scientific. Unfortunately, because of its current political and economic dominance, conventional medicine is in the position to dictate (through economic and publication control) that research, and therefore the scientific method will be applied primarily to itself. The result is that most conventional practitioners dismiss vitalistic medicine, along with all alternatives, as unscientific. Ironically, most vitalistic physicians also have extensive training in mechanistic and/or conventional medicine. Generally, they are capable of practicing mechanistically and do so to greater or lesser degrees. 

NATUROPATHIC PHILOSOPHY Vis Medicatrix Naturae Naturopathic physicians assert that all true healing is a result of vis medicatrix naturae (the healing power of nature). Unfortunately, some people in the field of alternative medicine (including some naturopathic physicians and students) have mistakenly translocated this concept to the therapy. These practitioners tend to operate as though this “healing power” is an intrinsic property of the natural therapy or medicinal substance itself. In contrast, proponents of vitalism and naturopathic medicine have always understood that the “healing power of nature” is an inherent property of the living organism. Vis medicatrix naturae is the living organism’s “desire” and ability to heal itself. As mentioned, the homeostatic process best exemplifies this. Historically, naturopathy is a vitalistic system of medicine. However, over the past 130 years its eclecticism has allowed it to incorporate a

CHAPTER 5  number of therapies that can function mechanistically. What makes these mechanistic therapies acceptable, given naturopathic medicine’s vitalistic foundation, is the emphasis on meeting each patient’s pragmatic health care needs. So the application of vis medicatrix naturae in practice is constantly adjusted depending on the situation at hand. Ideally, naturopathic practice involves only the use of therapies that support the organism and encourage its intrinsic healing process to work more effectively while avoiding the use of medicines and procedures that interfere with natural functions or have harmful side effects. Natural medicines and therapies are therefore preferred, because when they are used properly and in appropriate circumstances, they are the least harmful, least invasive, and best able to work in harmony with the intrinsic natural healing process. In addition, their constituents have been encountered in nature for millions of years. This long period of exposure has enabled the body to develop metabolic pathways capable of effectively using, processing, and detoxifying these medicines. The total organism is involved in the healing attempt, so the most effective approach to diagnosis and treatment is to consider the whole person. In addition to physical and laboratory findings, important consideration is given to the patient’s attitude, psychological and spiritual state, social circumstances, lifestyle, diet, heredity, and environment. Careful attention to each person’s unique individuality and susceptibility to disease is critical to the proper evaluation and treatment of any health problem. Naturopathic physicians contend that most disease is the direct result of the ignorance and violation of what would be traditionally called “natural living laws.” These general lifestyle rules (including diet) are based on the concept that there is an environment (both internal and external) that optimizes the health of an organism. Analysis of the lifestyles of Paleolithic and healthy primitive and modern cultures gives naturopathic physicians and their progenitors many clues as to what a healthy lifestyle should involve. Throughout most of modern history, biomedical science has focused primarily on researching the sick. Recently it has finally begun to evaluate what constitutes a healthy lifestyle. To no one’s surprise, this lifestyle looks like the same one advocated by naturopaths for the past 130 years. A healthy lifestyle could be generalized to include the following: • Consuming natural unrefined foods • Getting adequate amounts of exercise and rest • Living a moderately paced lifestyle • Having constructive and creative attitudes • Connecting to other people socially • Being present to the spiritual aspects of life • Avoiding toxins and polluted environments • Maintaining proper elimination It is also important to control these areas during illness to remove as many unnecessary stresses as possible and to optimize the chances that the organism’s healing attempt will be successful. Therefore patient education and responsibility, lifestyle modification, and preventive medicine are fundamental to naturopathic practice. Although the practice of naturopathic medicine is grounded in vis medicatrix naturae, it also recognizes that mechanistic intervention in the disease process is sometimes efficacious and, at times, absolutely necessary. Therefore naturopathic physicians treat patients with a wide variety of vitalistic and mechanistic therapeutic modalities. It is the circumstances and the goal of the therapy that ultimately determines which approaches are used. Naturopathic physicians have a long-standing tradition of integrating the best aspects of traditional, alternative, and conventional medicine in the interest of the patient. As appropriate, patients are referred to other health care practitioners. Whenever possible, every effort is made to use all treatment

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techniques in a manner that is harmonious with the naturopathic philosophy. 

Natural Medicines and Therapies Traditionally, medicines administered and prescribed by naturopathic physicians have been primarily natural and relatively unprocessed. Four categories of natural medicines can be defined. The first consists of substances found in nature that have been only minimally processed. Examples include, but are not limited to, foods, clean air and water, and whole herbs. The early “nature cure” practitioners used this category primarily. The second category involves agents extracted or made from naturally occurring products. Although these medicines have undergone processing, their constituents are still in the form found in the original natural substance. These first two types of natural medicinal substances have synergistic constituents that allow their use at lower doses with a resultant broader and safer therapeutic index. Examples of this category are tinctures and other botanical extracts (some of which are standardized on one or more constituents known to be clinically effective), homeopathic medicines, glandular extracts, and other substances of animal origin. The third category of natural medicines comprises those highly processed medicinal substances that are derived from a natural source. Often everything has been removed from such substances but the identified active ingredient, and they no longer have any synergistic constituents. Examples of these are the many new nutraceuticals made from plant substances, constituents of biochemical pathways, enzymes, amino acids, minerals, vitamins, and other food extracts. The fourth category that may be considered natural are those manufactured medicines that are presumed to be identical to naturally occurring substances. They have the advantage of being less expensive and are typically available in higher concentrations. Examples of these manufactured natural medicines include bioidentical hormones, synthetic vitamins, and analogues of plant and animal constituents. However, their use is a compromise because: • It is difficult to determine whether they are the equivalent of the natural product. • They lack natural synergistic components. • They may include contaminants from the manufacturing process; these contaminants are often chemically and structurally similar to the desired medicine but generally interfere with the normal pathways rather than enhance them. Naturopathic physicians also use many natural physical therapies. What makes a therapy natural is that it is derived from a phenomenon of nature and is used to stimulate the body to heal itself. Examples of these phenomena are air, light, heat, electricity, sound, and mechanical force. Some of these natural therapies are mechanical and manual manipulation of the bony and soft tissues (naturopathic manipulative therapy), physiotherapy modalities (e.g., electrotherapy and ultrasound), hydrotherapy, and exercise therapy. Naturopathic physicians also use lifestyle modification, counseling, and suggestive therapeutics. These therapies are all discussed in more detail in other chapters. 

Family and Specialty Practice Naturopathic physicians, like other types of primary care providers, develop practices that meet their personal interests and skills. Although most are engaged in general and family practice, some also specialized in particular therapeutic modalities and/or types of health problems. In all situations, however, the emphasis is still on treating the whole person. The practice of family medicine requires the use of some medicines, techniques, and devices that are not natural but belong among the comprehensive family practice services offered by the naturopathic profession.

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In the modern era of naturopathic medicine many states have expanded the scope of practice so that naturopathic physicians now practice much like other primary care practitioners with pharmaceutical prescribing rights. However, naturopathic physicians generally approach the use of pharmaceuticals differently than conventional physicians. They are seen as temporary interventions to be used to support the patient while other, more vitalistic natural therapies are used to help the patient recover his or her health with the ultimate goal of no longer needing the pharmaceutical. Many naturopaths have also developed advanced expertise in specific natural therapeutic modalities. These practitioners have usually invested in postgraduate training, such as that available through residencies. Three therapeutic specialties that merit mention are natural childbirth, acupuncture, and homeopathy. There is also a growing trend of specializing in organ systems (e.g., gastroenterology) or diseases (e.g., cardiology). 

THE PHILOSOPHICAL CONTINUUM When the various healing systems are examined and placed on a philosophical continuum, mechanism and vitalism are on different ends of the same health care spectrum. Both ends of this health care continuum have their strengths and weaknesses. Mechanistic medicine is effective for trauma, crisis care, end-stage disease, and many acute disorders. However, it is clearly a failure for most chronic disease. Conventional medicine considers most chronic diseases incurable. Vitalistic medicine, in contrast, has its most dramatic successes with chronic disease and is effective with many kinds of acute disease. It is not very effective with trauma and crisis care or with end-stage disease, although it can be a very useful complement to conventional medicine. As can be seen, both ends of the health care spectrum are necessary if every patient’s health care needs are to be met. Although aspects of naturopathic medicine (e.g., constitutional hydrotherapy) and conventional medicine (e.g., chemotherapy) represent the archetypes of vitalism and mechanism, the space between the ends of this spectrum is a gray area within which both naturopathic and conventional physicians operate on a continual basis. Naturopathic physicians integrate vitalistic therapies with mechanistic therapies, but it is not possible for everyone to be experts in everything.

The vast majority of naturopathic or conventional physicians cannot learn and competently practice all types of health care. Consequently, to effectively meet society’s health care needs, it is necessary to create an integrated/collaborative health care system. Such a system would have both vitalistic and mechanistic practitioners working together in the same clinical settings. The trends of popular culture and biomedical science that are finally beginning to study alternative medicine suggest that the creation of an integrated health care system is now well under way. However, it takes no great skill for a mechanistic medical doctor to switch from giving a synthetic drug for a disease to giving a natural medicinal substance (both mechanistically oriented interventions) without understanding vitalistic thinking. If naturopathic medicine becomes just another mechanistic system using natural medical substances to treat disease (instead of a system identified with treating the whole person vitalistically), it will lose its unique niche in an integrated health care system. To survive and thrive in this new environment, naturopathic medicine must keep its vitalistic roots. With a thorough grounding in vis medicatrix naturae, modern naturopathic medicine will flourish and achieve a leadership position as the dominant health care paradigm shifts to the integrated medicine of the future. 

CONCLUSION The practice of naturopathic medicine can be summarized most simply as helping the body–mind heal itself in the least invasive, most fundamentally curative manner possible. This approach is not tied to any particular therapy or modality, but rather is oriented to a rational blend of vitalistic and mechanistic principles working with the whole person and educating the patient in the ways of health. As naturopathic knowledge of health and disease grows, new therapies and approaches to health care will be added as they satisfy the principle of vis medicatrix naturae. With integration of the larger health care system, naturopathic medicine’s place is assured as the profession that truly understands each unique human being’s power to heal.

REFERENCES See www.expertconsult.com for a complete list of references.

REFERENCES 1. A thorough review of all health care modalities in use today reveals some that could be considered metaphysical. These include such things as prayer, faith healing, psychic healing, healing touch, touch for health, and medical dowsing. Generally speaking, the actual operator of the therapy must call on God or have some special endogenous skill or “power” that goes beyond intellectual knowledge. This makes these modalities “operator-dependent” and, thus, cannot be validated separately from the practitioner—greatly increasing the difficulty of their scientific verification. Consequently, these modalities are not historically relevant to this discussion of medical philosophy.

FURTHER READING Baer HA. The potential rejuvenation of American naturopathy as a consequence of the holistic health movement. Med Anthropol. 1992;13:369–383. Coulter HL. Divided Legacy. Richmond, CA: North Atlantic Books. Coulter HL. Homeopathic Science and Modern Medicine. Richmond, CA: North Atlantic Books. Dubos R. Mirage of Health: Utopias, Progress, and Biological Change. New York: Harper.

Kirchfeld F, Boyle W. Nature Doctors: Pioneers in Naturopathic Medicine. Portland, OR: Medicina Biologica. Lindlahr H. Philosophy of Natural Therapeutics. Maidstone, Kent, UK: Maidstone Osteopathic Clinic. McKee J. Holistic health and the critique of western medicine. Soc Sci Med. 1988;26:775–784. McKeown T. The Role of Medicine: Dream, Mirage or Nemesis? Oxford: Basil Blackwell; 1980. Payer L. Medicine and Culture: Varieties of Treatment in the United States, England, West Germany, and France. New York: Henry Holt and Company. Schubert-Soldern R. Mechanism and Vitalism: Philosophical Aspects of Biology. South Bend, IN: University of Notre Dame Press. Selys H. The Stress of Life. New York: McGraw-Hill. Sinnott E. The Bridge of Life: From Matter to Spirit. New York: Simon and Schuster. Spitler HR. Basic Naturopathy: A Textbook. New York: American Naturopathic Association. Zeff JL. The process of healing: a unifying theory of naturopathic medicine. J Nat Med. 1997;7:122–125.

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6 Placebo and the Power to Heal Peter W. Bennett, ND

OUTLINE Introduction, 87 Placebo Response, 88 Why study the placebo effect?, 88 History of Placebo, 89 Origin of the Term Placebo, 89 Clinical Observations of “Known” Placebo Therapy, 89 Other Clinical Observations, 90 Placebo Myths, 90 Myth 1, 90 Myth 2, 90 Myth 3, 91 Myth 4, 91 Pharmacodynamics, 91 Packaging and Delivery, 91 Placebo Interactions, 91 Placebo Healing Mechanisms, 92 The Role of Emotions, 92

The Vis Medicatrix Naturae, 92 Conscious Control Over Homeostasis, 92 Neurophysiology of Placebo Response, 93 Placebo and Stress Physiology, 93 Physiological and Psychological Stress, 94 Endorphins, Hormones, and Neuropeptides, 94 Clinical Application, 95 Prima Non Nocerum: Prioritize a Treatment Program and Establish a Hierarchy of Care, 95 Tollem Causum: Remove the Cause of Disease, 95 Support the Therapeutic Relationship, 96 Enhance Positive Emotional States, 96 Implement Therapeutic Conditioning or Learning, 98 Use Altered States of Consciousness, 99 Ethics, 101 Conclusion, 101

INTRODUCTION

As time marches on, medicine is beginning to acknowledge, stimulate, and utilize the subliminal healing capacity of the mind. A review of the placebo literature in Lancet2 concluded that the placebo effect has a complex physiological multisystem dimension and should be encouraged in the clinical situation to optimize health and healing—a perspective reached by this author 30 years ago and published in the first edition of this textbook. In November 2000, 17 health centers and agencies gathered together for 3 days to explore the science of self-healing hidden in the power of placebo. This conference focused on the powerful mind–brain physiology of the placebo effect and its potential for affecting the course of human disease.3 One of the conclusions of the conference was that the “placebo response” has potential use for medical application and needs further exploration. Research has shown that the impressions and thoughts in a patient’s mind, the attending physician’s intention, and the combined effect of their relationship have a measurable effect on the health of the patient. The ability of the patient’s mind to affect the process of virtually every disease has been well documented,4,5 and the internal mechanisms and pathways by which the mind can positively or negatively affect the immune and healing processes has been investigated in the scientific literature of psychoneuroimmunology.6,7 As the body of knowledge documenting the critical role of the patient’s psyche in the therapeutic environment has grown, it has become increasingly important for all schools of medicine to teach the healing potential of the human mind. Conventional medical thinking has turned its opinion of the placebo effect from that of a 19th-century pejorative to a concept that sums up the complex mind–body interactions affecting the power of

As living organisms, we have evolved with an innate capacity for self-healing. In the clinical setting, naturopathic physicians have always relied on this self-healing capability of the individual. The healing power of the mind and body, the “life force,” is a cornerstone of naturopathic philosophy and treatment. Naturopathic physicians describe this with a phrase attributed to Hippocrates: vis medicatrix naturae. The “inner” power to heal is one of the great mysteries of medicine, and it behooves us as physicians, regardless of our licensing body, to understand the biology and physiology that surround the processes that guide and control this phenomenon. Following this logic, a central problem to be explored and considered is that placebo response has shown medical science that the mind of a patient has a powerful role in therapy. Although the dictionary definition of mind is described as a person’s thoughts and consciousness, centuries of writings from many societies and cultures on philosophy, religion, psychology, cognitive science, neuroscience, and artificial intelligence have struggled to clearly define the complex interaction of personality, emotion, perception, memory, thinking, judgment, and spiritual insight. Adding to the difficulty of the semantics of exploring the healing power of the mind is the difficulty to definitively define the scope of physiology and function of the mind.1 Because the definition and understanding of the human mind challenge a consensus of our collective insight and understanding, it is natural that the function and uses of placebos are an area of myth and misunderstanding rather than an area of wisdom and insight.

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people to heal.3 Unfortunately, the most modern abuse of the concept of the placebo comes from biased critics of alternative medicine who have chosen to label the beneficial effects of these therapies as merely from the placebo. These critics dismiss the science of natural healing as an imaginary phenomenon and the last resort for quack doctors who have no real medical treatments to offer their patients.8 The most interesting aspect of the placebo literature is the exploration of the extent of the potential of the mind to influence human health. The “power of placebo” draws on the innate ability of the body to spontaneously heal itself, a fundamental principle of naturopathic medicine. This point separates the care delivered by naturopathic physicians from the pharmaceutical and surgical approaches of current medical “standard-of-care” procedures. If common medical texts on internal medicine or ambulatory care are examined, the word healing is not found in the index. Except for the diagnostic evaluation of “self-limiting diseases” and “spontaneous regression,” the ability of the human organism to self-right and repair from a state of acute or chronic disease is not explored in modern medicine except under the designation “placebo response.” The placebo response therefore represents all the “unknown” variables that conspire to heal a patient despite pharmaceutical and surgical intervention. Although it seems to be a natural area to develop in clinical and hospital settings, the fundamental separation of mind and body in conventional medical thinking may be slowing down a standardization of care that actively engages the hopes and beliefs of all patients undergoing treatment. 

PLACEBO RESPONSE The placebo response represents the power of the mind, through intention, to effect (1) a change in oneself, (2) a change in those around one, and (3) a change in the environment in which one lives. Intention has been observed to affect machines9 and remote biological systems.10 Distantly influenced systems include another person’s electrodermal activity, blood pressure, and muscular activity; the spatial orientation of fish; the locomotor activity of small mammals; and the rate of hemolysis of human red blood cells. Prayer, an example of intention, has been extensively studied as a therapeutic healing modality.11 One study showed a dramatic result in cardiac intensive unit recovery when patients were prayed for by someone at a distant location.12 Patients in this study were 5 times less likely to require antibiotics, 3 times less likely to experience pulmonary edema, 12 times less likely to require endotracheal intubation, and significantly less likely to experience cardiac mortality. Our biological systems must conform to the laws of physics. Modern physics has investigated the effect of an observer on the system observed. It has been shown that an electron will acquire a definite axis of measurement in the process of measurement. Bell’s theorem supports the idea that our universe consists of particles unified instantly as an indivisible whole; our biological homeostatic systems cannot be analyzed in terms of independent parts. The interconnected nature of our biological systems has been known for thousands of years; the ancient Buddhist concept of “interdependent phenomena” or Pratītyasamutpāda accurately describes this paradigm. The Buddhist concept of interconnectedness and interdependency does not imply a Newtonian billiard-ball effect of a cause or causation, but rather an interdependent “held” state of a plurality of conditions and causes. The idea that a healing response can be generated without genuine causation, such as drug treatment, seems to violate the laws of biological systems. Comparing the healing response generated by a thought or intention might not violate the laws of physics, but it has a difficult place in a medical philosophy of cause and effect driven by pharmacodynamics. Interestingly, humans are not the only organisms to be

affected by the placebo response; it has been observed in Caenorhabditis elegans and the fruit fly Drosophila melanogaster through cell signaling indicating a phenotypic response to sensory input, which shows that the placebo phenomenon is not ignoring cause and effect—it merely indicates the potential for more subtle self-regulation than that referenced in modern medical standards of care.13 Our current medical system is gradually shifting with the developments in modern physics. These modern ideas of biological systems are diametrically opposed to Cartesian paradigms that our internal and external environment consists of separate parts joined by local connections. Medicine must take a “quantum leap” to catch up with the knowledge we possess about our environment through quantum physics. We can see clearly that it is impossible for a doctor to observe a patient without that observation having an effect on the health of the patient. Pierre Teilhard de Chardin postulated, and Rupert Sheldrake proved, the possibility of a “morphogenetic field” for the subliminal communication to all members of our species.14 The effect of human thought on other members of society has been described in human society since the beginning of our earliest cultures. Naturopathic physicians believe that the body has a powerful ability to maintain health and repair to a healthy state after disease by virtue of its inherent power of vitality. This homeostatic healing mechanism has been selected by nature in the same way that the organs that we consider to be vital to our survival have been selected. Healing happens unaided by simply maintaining an environment that does not obstruct the path of cure. Because the placebo literature documents the philosophical foundations of the naturopathic healthcare model, it is important to review the full scope of this subject. Integrating known placebo initiators in clinical practice is essential for good patient care. 

WHY STUDY THE PLACEBO EFFECT? For hundreds of years, physicians have watched their patients respond to therapies with a wide range of results. Some patients recover fully, whereas others, with apparently identical diseases and therapies, wither and die. Today, a skilled physician can correctly diagnose the condition of a patient by applying the sophisticated techniques of modern medicine. Then, an appropriate therapy, the efficacy of which has been thoroughly proven in research and clinical trials, can be prescribed. Through this process the patient will have received the best care available through current medical technology. However, if the diagnosis, therapy, and therapeutic interaction do not stimulate the hope, faith, and belief of the patient, the chances of success are measurably diminished. In the literature on the placebo effect15; psychoneuroimmunology6; and psychosomatic,16 behavioral,17,18 and psychiatric19 medicine, it has been repeatedly demonstrated that the beliefs of both the patient and the doctor, and their trust in each other and the process, generate a significant portion of the therapeutic results.20 The placebo and its effect are not separate from any aspect of the therapeutic interaction, nor are they “nuisance variables” muddying a clear clinical picture. Rather, they send the physician a strong message: it is a patient’s own belief system that mobilizes the inherent healing powers of the mind. By studying the placebo effect, a physician is better able to fully harness this power to trigger internal healing mechanisms. Yet despite the quantity of documentation, the placebo effect remains one of the most misunderstood areas in modern medicine. The physician should always strive to stimulate self-healing, or the placebo effect, as fully as possible to maximize its potential for healing. Someday physicians will be able to explore the deepest recesses of the unconscious to directly access therapies that assist the body in the

CHAPTER 6  restoration of internal homeostasis. The optimal model for health care is the marriage of appropriate medical technology with the factors that have been shown to generate the placebo effect. This exciting scenario shines on the horizon as the health care of the future. Because the doctor–patient relationship is such fertile ground for stimulating the healing response,21–23 it serves a physician well to comprehend the nature of the placebo phenomenon to fully realize this potential for healing. 

HISTORY OF PLACEBO Both the modern physician and primitive medicine men and shamans of the past used ineffective therapies to stimulate healing in their patients. As Shapiro observed, “the true importance of placebo emerges with a review of the history of medical treatment.”24 It was noted that the historical therapies of the medical profession and traditional healers, “purging, puking, poisoning, puncturing, cutting, cupping, blistering, bleeding, leeching, heating, freezing, sweating, and shocking,”25 worked because of the placebo effect. Although these practices might seem ludicrous in retrospect, all of these therapies were once considered effective. As an embarrassing epilogue, the placebo literature shows that ineffective procedures are just as pervasive in modern medicine as in the jungle hut of the shaman. We must therefore ask ourselves how unfounded medical therapies can survive peer-reviewed literature and centuries of cultural acceptance. The power of the patient’s belief in the potential for a cure has been consistently observed throughout history. Both Galen and Hippocrates recognized the strong effect of the mind on disease and recommended that faith, treatment ritual, and a sound doctor– patient relationship could provide important therapeutic results.26 Recognition of the power of positive expectation was recorded frequently in the medical literature of the 17th and 18th centuries. It was in the 18th century that the use of placebos was first defined as a “commonplace method of medicine.”27 As the importance of drug therapy grew in the 19th century, the term placebo became identified with medicines involving substances that resembled drugs. However, in the 1940s, because of the increase in double-blind research, it became associated with inert substances that were used to replace active medication. 

ORIGIN OF THE TERM PLACEBO The original Latin meaning of placebo is “I shall please.”28 Although the term had a purely medical application in the first half of the 20th century, its meaning has been subject to various interpretations throughout the past several hundred years. Before the 1940s, placebos were pharmacologically inactive substances, such as saline and lactose pills, used to satisfy patients that something was being done for them—in other words, the doctor was “pleasing” the patient. The 1940s and 1950s saw an explosion of the use of double-blind experimental procedures to evaluate the growing number of new drugs and medical procedures. Suspicion arose that all medical therapies contained an element of the placebo phenomenon.29 This new understanding pressed the scientific community to offer new, far broader definitions. Shapiro25 offered the classic definition of a placebo: Any therapeutic procedure (or that component of any therapeutic procedure) which is given deliberately to have an effect, or unknowingly has an effect on a patient, symptom, syndrome, or disease, but which is objectively without specific activity for the condition being treated. The therapeutic procedure may be given with or without

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BOX 6.1  Types of Placebos 1. Known placebo: Placebo used in a single-blind experiment. The doctor knows it is a placebo, but the patient does not. 2. Unknown placebo: Double-blind use of placebo. Neither the doctor nor the patient knows that the medication is a placebo. 3. Active placebo: Any substance that has an intrinsic physiological effect that is irrelevant to the ensuing placebo effect. The vasodilating effect of niacin would make it a good active placebo. 4. Inactive placebo: Any substance that is used with medicinal intent but that has no inherent physiological effect. Aside from the glucose effect in a sugar pill (or, to complicate things, an allergic reaction to some component of the supposedly inert substance), it has no physiological effect. 5. Placebo effect: Any changes that occur in a patient as the result of placebo therapy. 6. Nocebo effect: Any changes that occur as a result of placebo therapy that are perceived as negative or counterproductive to the path of cure.

the conscious knowledge that the procedure is a placebo, may be an active (non-inert) or inactive (inert) procedure, and includes, therefore, all medical procedures no matter how specific—oral and parenteral medications, topical preparations, inhalants, and mechanical, surgical, and psychotherapeutic procedures. The placebo must be differentiated from the placebo effect which may or may not occur and which may be favorable or unfavorable. The placebo effect is defined as the changes produced by placebos. The placebo is also used to describe an adequate control in research. A more accurate definition would be the following: The placebo effect is the process of a physician working with the self-healing processes of a patient. The placebo response is healing that results from the patient’s own natural survival and homeostatic defense mechanisms. Modern placebo definitions extend to its nature, properties, and effects. A placebo can be known or unknown, active or inactive, positive or negative in results (placebo effect vs. nocebo effect), and can extend to all forms of diagnostic or therapeutic modalities,30 as further defined in Box 6.1. 

CLINICAL OBSERVATIONS OF “KNOWN” PLACEBO THERAPY One of the more dramatic examples of the placebo effect reported in the medical literature involved a patient with advanced lymphosarcoma, which Klopfer31 reported was highly susceptible to the patient’s faith in an experimental drug called Krebiozen. When the patient was started on the drug injections, his enthusiasm was so intense that “The tumor masses had melted like snowballs on a hot stove, and in only a few days, they were half their original size!”31 The injections were continued until the patient was discharged from the hospital and had regained a full and normal life, a complete reversal of his disease and its grim prognosis. Within 2 months of this recovery, reports that the drug Krebiozen was ineffectual were leaked to the press. Learning of this report, the patient quickly began to revert to his former condition. Suspicious of the patient’s relapse, his doctors decided to take advantage of the opportunity to test the dramatic regenerative capabilities of the mind; a single-blind study was performed on the patient using pure placebo. He was told that a new version of Krebiozen had been developed that overcame the difficulties described in the press, and some of the drug was promised to him as soon as it could be procured.

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BOX 6.2  Symptoms and Side Effects of

Placebo Response

• Anger206 • Anorexia51 • Behavioral changes207 • Depression62 • Dermatitis medicamentosa51 • Diarrhea51 • Drowsiness62 • Epigastric pain51 • Hallucinations56 • Headache208 • Lightheadedness51 • Palpitation51 • Pupillary dilation36 • Rash51 • Weakness51

With much pomp and ceremony, a saline water placebo was injected, increasing the patient’s expectations to a fevered pitch. The recovery from his second near-terminal state was even more dramatic than the first. Tumor masses melted, chest fluid vanished, he became ambulatory, and he even went back to flying again. At this time he was certainly the picture of health. The water injections were continued because they worked such wonders. He then remained symptom-free for more than 2 months. At this time, the final American Medical Association announcement appeared in the press—“nationwide tests show Krebiozen to be a worthless drug in the treatment of cancer.” Within a few days of this report, the patient was readmitted to the hospital in extremis. His faith was now gone, his last hope had vanished, and he succumbed in less than 2 days.31 Other famous placebo case studies are one reported by Cannon32 on “voodoo death” caused by belief and one reported by Kirkpatrick,33 who documented the spontaneous regression of lupus erythematosus resulting, in part, from the patient’s belief in the removal of a curse.

Other Clinical Observations Belief sickens, belief kills, belief heals.34 Evans35 and Beecher36 reviewed, between them, 26 double-blind studies on the efficacy of active analgesic drugs in the treatment of pain. Independently, they concluded that 35% of patients with pain experienced a 50% reduction in their symptoms after placebo medication. These were particularly remarkable results when viewed in the context of Evans’s observation that with a standard dose of morphine, only 75% of the patients experienced a 50% reduction in pain. In calculating the efficiency index of placebo analgesia, a method often used to determine the relative efficiency of drugs, placebo was 0.56 as effective as a standard dose of morphine. This prompted Evans to remark, “Thus, on average, placebo is not a third as effective as a standard injection of morphine in reducing severe clinical pain of various kinds but is in fact 56% as effective.”35 As discussed previously, the placebo phenomenon has been evaluated in a wide variety of clinical settings in addition to pain management (Box 6.2). When a phenomenon such as the placebo effect has been observed to be active in diverse clinical situations, such as surgery, drug therapy, psychotherapy, and biofeedback, and over a range of physical and mental symptoms, the conclusion that it must be a factor in all aspects of medicine is inescapable.

In addition to the variety of positive effects that placebos produce are the nocebo effects, perceived as counterproductive to the therapeutic goals. Widely ranging negative side effects to placebos have been reported in the medical literature.37 These side effects are frequently consistent with those of the medication that patients believe they are getting. For example, the studies that measure the effects of a supposed aspirin usually show nocebo effects of ulcerlike pain.38 One study showed that suggestion seems to be a primary cause of nocebo reactions, in contrast to the strong conditioning component found in the placebo response.39 In homeopathy, aggravations and ameliorations are commonly seen when a placebo is given to fend off a patient’s need to take a medication while the homeopathic physician is waiting to see whether a high-potency remedy will effect a cure. Homeopathic doctors report that placebos can cause anxiety and loneliness as well as calmness and immediate relief from insomnia.40 

PLACEBO MYTHS An investigation of the understanding of placebos found in the current medical literature revealed the misconceptions that prevail about the nature of placebo therapy and its effectiveness.40 A study undertaken to examine doctors’ and nurses’ attitudes about the efficacy and use of placebos showed that both groups underestimated the number of patients who could be helped by placebo.41 Physicians showed a consistent pattern of placebo use, as follows: • Placebos were used to prove the patient wrong through the diagnosis of psychogenic symptoms in patients who were thought to be exaggerating, imagining, or faking their symptoms. • Placebos were used in the treatment of alcoholic, psychotic, and demanding patients who were disliked by the staff of the hospital. • Placebos were used as a treatment in situations in which standard treatments failed or the patient was getting worse. These misconceptions regarding the nature of the placebo accounted for its widespread misuse in patients who were perceived as uncooperative or who were suspected of malingering. Myths about placebos continue to hinder a full understanding of the power inherent in this aspect of health care. The most common myths are discussed here.42

Myth 1 “Because placebos tend to be physiologically inert, it is not possible for them to have an effect on physiological homeostasis.” Fact: Research shows that placebos have a wide range of effects (Table 6.1) that are found throughout all aspects of human physiology. 

Myth 2 “Placebos are useful only with symptoms that are associated with psychological or psychosomatic complaints. Patients who need a placebo are hypochondriacs with vivid imaginations and need to be palliated with something to please them.” Fact: Placebos have been shown to be effective in the care of all types of patients, with a consistent level of positive results for a wide variety of accurately diagnosed diseases. Beecher20 was one of the first to compile a listing of the therapeutic effectiveness of placebo, thereby uncovering the wide range of therapeutic applications that were previously thought to be limited only to pain control. He concluded, “there is too little scientific as well as clinical appreciation of how important unawareness of these placebo effects can be and how devastating to experimental studies as well as to sound clinical judgement lack of attention to them can be.”20

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Placebo and the Power to Heal

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TABLE 6.1  Physiological Changes Induced

BOX 6.3  Conditions That Have Been Shown

Physiological Function

• Angina54,190,191,209,210 • Anxiety51,211,212 • Arthritis38,168,213 • Asthma214–217 • Behavioral problems218 • Claudication, intermittent193 • Common cold219–222 • Cough223 • Depression224,225 • Diabetes (non–insulin-dependent diabetes mellitus)196,197 • Drug dependence51 • Dysmenorrhea226 • Dyspepsia227 • Gastric ulcers228 • Hayfever229,230 • Headaches, temporal and vascular 231–233 • Hypertension234,235 • Labor and postpartum pain236 • Premenstrual syndrome237 • Ménière’s disease238 • Nausea of pregnancy51 • Pain106,239 • Psychoneuroses52,240 • Rhinitis241 • Sleep disturbances242 • Tremor54

by Placebo Heart

Sympathetic stimulation Claudication Opioid dependence Postsurgical trauma Diabetic blood sugar dyscrasias (NIDDM) Gastrointestinal secretion and motility Hypertension Motor dysfunction

Physiological Changes tolerance190,191

Improved exercise Decreased serum lipoproteins192 Improved T waves57 Decreased pulse rate and arterial pressure59 Decreased tremulousness, sweating, and tachycardia51 Increased walking distance193 Addictive drug withdrawal194 Decreased facial swelling195 Lowered fasting blood sugar196,197 Decreased gastric acid secretion198 Changes in gastric motility165,199 Healing of duodenal ulcers200 Lowered blood pressure201–203 Reduced urinary catecholamines204 Improved tremor magnitude205

NIDDM, non–insulin-dependent diabetes mellitus.

The large and ever-growing number of studies on placebos and double-blind research (Box 6.3) supports the following assertion made by Beecher20 30 years ago: Many “effective” drugs have power only a little greater than that of placebo. To separate out even fairly great true effects above those of placebo is manifestly difficult to impossible on the basis of clinical impression. Many a drug has been extolled on the basis of clinical impression when the only power it had was that of a placebo. 

to Respond to Placebo

that in any given situation, responses to a placebo may vary as compared to any other situation and the significance of situations to human subjects cannot be precisely duplicated.51 

Myth 3 “The placebo effect is found only with substances that are inert.” Fact: The placebo phenomenon has been observed across a wide spectrum of medical disciplines including surgery,43 drug therapy,44 and biofeedback.45 

Myth 4 “The patient who responds to placebo therapy can be characterized as someone who is of a typical neurotic disposition.”41 Fact: Although many studies have tried to impute a personality type, disposition,45,46 or certain epidemiological class47 to the patient who responds to placebo, this has yet to be well demonstrated because, in the right circumstances, any person can become a placebo reactor.48,49 After reviewing the bulk of the research on this subject, Bush50 and Wolf and Pinsky51 concluded that the attempts to pigeonhole personalities into a clinical profile ignored the complexity of the human mind. Gliedman et al.52 similarly reported that age, sex, marital status, social class, and intelligence were unimportant factors in determining a patient’s response to placebo. Wolf summarized that attempts to identify placebo reactors need to identify the nature of the symptom being treated, the motivation of the patient and physician, the nature of the test agent, its mode of administration and the life situation of the subject at the time he is tested. The significant point here is not the apparently conflicting findings of investigators with respect to placebo reactors, but rather

PHARMACODYNAMICS The physiological response of the “inert and inactive” placebo extends into the realm of drug pharmacodynamics. Dose–response time curves, cumulative effects (increasing therapeutic efficacy with repeated doses),53 variable strengths of analgesia based on a patient’s drug expectation,54 drug interactions,51,55 and carryover effects46,56 have all been demonstrated. The effects of placebos are so pronounced that some observers have suggested that they can exceed the effects attributable to potent pharmacological agents.51

Packaging and Delivery Several studies found that the effectiveness of placebo therapy depends on the mode of delivery.57 For example, one study found that green tablets improved anxiety and yellow tablets improved depression,58 whereas another study found that blue capsules were more sedative and pink capsules were more stimulating.59 Placebo injections appeared to be more effective than oral administration after oral placebo has failed to relieve the patient’s symptoms.38 

Placebo Interactions Benson60 wrote that the patient’s belief was also a powerful force in determining the level of relief afforded by the placebo. An increase in patient expectation enhances the physician’s ability to elicit a placebo response. Even if patients know that they are receiving placebos, the expectation and relief brought about by the therapeutic interaction

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provide positive results.61 The importance of expectation was further demonstrated by the observation that the greater the stress level of the patient and the greater his or her need for assistance, the greater the effectiveness of placebo.62 This was seen even in patient responses to psychotropic drugs: d-lysergic acid diethylamide tartrate 25 (LSD25) could have no effect if the patient was told that the drug was a placebo.45,63 Patients, such as war heroes, who had severe injuries but did not have great mental suffering attached to their pain needed less pain medication than persons with similar injuries who had pain that engendered anxiety and connoted disaster.64 

PLACEBO HEALING MECHANISMS When animals or humans can react to their own deviations from homeostasis and when these deviations set off restorative processes, therapeutic intervention, including placebo, has an already existing substrate of recovery for exploitation.17 A human being has an intrinsic ability to “self-right”—vis medicatrix naturae (the healing power of nature). This is the keystone of a philosophy that has been held for thousands of years by naturally oriented physicians (see Chapter 5). The concept of a homeostatic, self-regulating mechanism is central to the understanding of basic concepts of physiology: negative feedback loops control virtually all systems of the body. According to Guyton,65 “the body is actually a social order of about 75 trillion cells organized into different functional structures.… [E]ach cell benefits from homeostasis and in turn each cell contributes its share toward the maintenance of homeostasis.” The body can maintain health and reestablish a healthy state after disease by virtue of its inherent vitality. This is part of the definition of a homeostatic mechanism; it has been selected by nature in the same way that organs vital to our survival have been selected. The surviving species are those most fitted and best able to cope with dysfunction. Those organisms that can tolerate the greatest stresses and still maintain normal physiology are the hardiest survivors and ensure the species’ ability to increase the limits of its adaptation. Therefore, given that an organism is self-maintaining when in an environment that it has been selected for, healing happens unaided through simply maintaining an environment that does not obstruct the path of cure. As Norman Cousins66 observed, “without any help, the human body is able to prescribe for itself. It does so because of a healing system that is no less real than the circulatory system, the digestive system, the nervous system, or any of the other systems that define human beings and enable them to function.”

The Role of Emotions Starting in the 1970s and early 1980s, review articles began to examine the effect of the mind on the immune system, emphasizing mechanisms and pathways that gave rise to a new field called psychneuroimmunology.5 Reviews of studies that explored how specific emotions can increase cancer susceptibility,67,68 examined the effect of emotions and recovery from cancer,69 investigated the increased incidence of sudden and rapid death during psychological stress,70 and monitored the changes in immune function during emotional stress71,72 all confirmed that emotions play a powerful role in the prognosis of a patient. Cannon32 and Tregear73 documented dramatic case histories of pioneering anthropologists who witnessed the power of taboos and curses to kill strong, healthy men and women in third-world cultures throughout Africa, South America, and the South Pacific. Tregear73 wrote, “I have seen a strong young man die the same day he was tauped [tabooed]; the victims die under it as though their strength ran out as water.” 

The Vis Medicatrix Naturae The healing process described as vis medicatrix naturae demonstrates the significant power and potential of the self-generated healing capacity. For a physician, there is no more powerful stimulator of this healing mechanism, the placebo effect, than a strong doctor–patient interaction. Just walking through the door of the physician’s office nudges a patient’s internal homeostatic mechanisms into seeking higher levels of health, healing, and adaptation. The placebo effect is a result or effect of the patient’s seeking the assistance of the doctor’s ability to heal and cure. As Benson60 noted, When we dissected the placebo effect a number of years ago, we found three basic components: One, the belief and expectation of the patient; two, the belief and expectation of the physician; and three, the interaction between the physician and the patient. When these are in concert, the placebo effect is operative.… Perhaps nothing is being transmitted from the healer to the patient, but rather it’s the belief the patient has in the healer that’s helpful. 

Conscious Control Over Homeostasis The body has two internal forces to maintain homeostasis: a lower drive and a higher drive. The lower drive is the inherent internal healing mechanism, the vital force, or the primitive life support and repair mechanism that can operate even in a person who is asleep, unconscious, or comatose. The higher drive is the power of the mind and emotions to intervene and affect the course of health and disease by depressing or stimulating internal healing capacities. The effect of this drive can be seen in the clinical observation of patients who move toward spontaneous remission of a life-threatening disease through positive emotional support15,69 and in patients who fail to express emotions compatible with the body’s attempts to survive.69 In any disease process, the consciousness of the patient decides the effectiveness of any therapy. It has been suggested that widely ranging nondrug stimuli have the capacity to modulate human functioning.74 It is emerging in the medical literature that any sensory stimuli or mental activity is able to alter disease progression. This extends to the thoughts and intentions of those connected to the patient. Experiments in remote intention–generated healing and prayer showed that the intention of others was a factor in the homeostatic capabilities of the mind and body. The fact that the homeostatic mechanism can sense and respond to these remote intentions is a reflection of the power of the human mind. Some authors believe that there is a physiological basis for the unlimited possibility of human voluntary control.75 The conclusion that awareness or “mind,” anyone’s mind—the patient, the doctor, or someone who is aware of the patient—can alter the patient’s physiology is a testament to the “holos” concept in different schools of alternative and complementary medicine. This idea flies so deeply in the face of our mechanistic model of medicine, it forces a complete paradigm shift in the conventional social ethos of medical care. The ultimate control of psyche over soma demonstrates the priority of the conscious mind over physiological processes such as immunity and pain control.76 This puts an enormous responsibility on the physician. He or she must take full account of a patient’s mental and emotional states when treating chronic or life-threatening disease.

Physiological Mechanisms Identification of a biochemical mechanism for placebo analgesia has done more to change the image of placebo therapy than any amount of arguing about the importance of beliefs and the mind.77 The mechanisms of the placebo response have been suggested to be a mixture of psychological interactions78 and cognitive states79 mediating physiological responses.19 The psychological components

CHAPTER 6  of the patient’s placebo effect have been shown to include decreased anxiety and increased relaxation,54 conditioning,18 expectation,23 and well-being generated by the establishment of a sound doctor–patient relationship.80,81 Review articles summarized a wide range of receptor-agonist mechanisms driving the neural pathways in different parts of the brain.82 To date, endorphin, dopamine, cholecystokinin, interleukins, growth hormone, and cortisol have been implicated. The physiological mechanisms of the placebo effect were suggested to include chemicals, catalysts, and enzymes. It is believed that steroids, catecholamines,15 the autonomic nervous system,19,83 neuropeptides, and endorphins84 are also involved. These physiological mechanisms interrelate synergistically and are currently being researched within the rapidly developing field of psychoneuroimmunology,7 through which the links between depression, affective disorders, emotions, and the immune system and central nervous system (CNS) are being explored. Susceptibility to depression and sensitivity to pain have now been found to be mediated through neurotransmitters such as catecholamines, serotonin, and dopamine. The current model for explaining the mechanism by which emotions, mood, and psychological stress suppress immune function involves cerebral–hypothalamic and pituitary interaction, which translates stress and anxiety into an autonomic–endocrine response. This response adversely affects the immune function, particularly after chronic stimulation. Stressful stimulation is received in the sensory cortex of the brain and is then referred to the limbic system and the hypothalamus. This interface of higher-brain functions and homeostatic regulating centers provides the communication link between the psyche and soma. According to Rossi,19 “The hypothalamus is thus the major output pathway of the limbic system. It integrates the sensoryperceptual, emotional, and cognitive function of the mind with the biology of the body.” The nerve centers that control both branches of the autonomic nervous system (both parasympathetic and sympathetic), nerve cells that secrete endocrine-releasing factors, and neural pathways that release hormones directly into the posterior pituitary are in the hypothalamus. The corticosteroids and catecholamines from sympathetic stimulation are key factors in the alteration of disease susceptibility in response to stress. Corticosteroids inhibit the function of both macrophages and lymphocytes, as well as lymphocyte proliferation.85 Corticosteroids also cause the thymic and lymphoid atrophy noted by Hans Selye in his experiments on stress-induced immune dysfunction.86 The autonomic release of catecholamines stimulates receptors on the surface of lymphocytes, thereby increasing their maturation rate. When lymphocytes are in a mature state, their ability to kill bacteria and cancer cells and produce interferon seems to become paralyzed.87 Thus a population of mature lymphocytes develops, ready to defend the body from infection and inflammation, yet remains paralyzed until the “red alert” signal of sympathetic fight or flight is turned off, signaling the appropriate time to rest and repair. A number of other peptides, E-type prostaglandins, somatotropin, histamine, insulin, endorphins, antidiuretic hormone, and parathyroid hormone all have receptor sites on lymphocytes and can stimulate the same cyclic adenosine monophosphate–mediated response resulting in lymphocyte maturation and inhibition.85 A study of the effect of catecholamines on the human immune system showed that when a physiological dose of epinephrine was injected into a healthy volunteer, there was an increase in the number of circulating suppressor T lymphocytes and a decrease in the number of circulating helper T lymphocytes (changes similar to those found in acquired immunodeficiency syndrome [AIDS]).85 

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Neurophysiology of Placebo Response Medical research has continued to expand the understanding of the placebo healing response, extending the understanding of the complexity of the brain functions that control healing in the body.88 One review article did an excellent job of summarizing the psychobiological mechanisms involved in the wide array of medical conditions observed in the placebo response literature.2 Imaging techniques such as positron emission tomography and magnetic resonance imaging (MRI) have literally illuminated the areas of the brain involved in generating the placebo effect.89 One fascinating development is the indication that the placebo effect may be especially useful in depression, anxiety, substance abuse, and neurodegenerative diseases like Parkinson’s disease and Alzheimer’s disease. Research has indicated that the conditioning and anticipation of the patient have a potent effect of stimulating specific brain region activity associated with pain modulation and neurohormonal regulation.

Brain Region Activity Some of the most interesting research on placebos has evolved out of the new MRI technology. This functional MRI (fMRI) can measure blood flow into specific areas of the brain. One study showed that expectation or hope was able to stimulate a certain part of the brain that is activated by pain medications and is associated with pain relief. Placebo analgesia was found to be related to decreased brain activity in pain-sensitive brain regions, including the thalamus, insula, and anterior cingulate cortex. It was also associated with increased activity during anticipation of pain in the prefrontal cortex, providing evidence that placebos alter the experience of pain.90 In another study, researchers found that empathy could activate a portion of the brain. They showed that some of the brain regions involved in feeling physical pain became activated when someone empathized with another’s pain. Using fMRI, study participants were observed when they experienced a painful stimulus, and the results were compared with those elicited when the participants observed their spouses receiving a similar pain stimulus. The bilateral anterior insula, rostral anterior cingulate cortex, brainstem, and cerebellum were activated when participants received pain and also by a signal that a loved one experienced pain.91 A group of researchers at the University of California at Los Angeles, using a new technology called quantitative electroencephalography, showed that “effective” placebo treatment induced changes in brain function that were different from those associated with antidepressant medication. Placebo responders (those who showed a response to placebo) showed a significant increase in prefrontal activity starting early in treatment that was not seen in medication responders or in participants who showed no response to medication or placebo. Because a high percentage of antidepressant medication represents the placebo effect, it is important to be able to predict who will be placebo responders.92 

Placebo and Stress Physiology The stress “letdown” of a patient in the therapeutic environment is one of the mechanisms that produces the placebo effect. It results from the patient’s perception that a transition from a stressful situation to a nonstressful situation has occurred. Mowrer87 observed that with a decrease in anxiety, there is a concomitant increase in hope, signifying that the period of suffering is over. Certain familiar images and signals, such as white coats, syringes, behavioral procedures, and clinical protocol, create a conditioned response—relief now that help has arrived. Evans and Hoyle54 similarly observed that “the reduction of fear through the shared expectations that the doctor’s medicine will work—even if unknown to the patient it is placebo—mediates powerful therapeutic effects.”

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The placebo effect in the clinical environment transforms the emotional and mental stress of the patient. These effects, also observed and described by Franz Alexander,16 Hans Selye,86 George Solomon,93 and Walter Cannon,94 allow the patient to escape the “fight-or-flight” response that can cause and maintain the state of illness. 

Physiological and Psychological Stress Selye86 demonstrated that physiological stress can have a dramatic effect on the immune and endocrine systems of the body. Laudenslager95 went on to show that it is not just stress that creates these physiological changes; the perception that stress is “inescapable” is critical to the response. More recently, studies on the effects of psychological stress demonstrated significant changes in immune capability. Maladjustment to “life-change stress” correlated with reduced activity of natural killer cells,93 decreased T- and B-cell responsivity,71 and diminished lymphocyte cytotoxicity.96 For example, Riley97 observed increased tumor activity in a controlled stress environment and concluded: Emotional, psychosocial, or anxiety-stimulated stress produces increased plasma concentrations of adrenaline, corticosteroids and other hormones through well-known neuroendocrine pathways. A direct consequence of these increased corticoid concentrations is the injury to elements of the immunologic apparatus, which may leave the subject vulnerable to the action of the latent oncogenic viruses, newly transformed cancer cells, or other incipient pathologic processes that are normally held in check by an intact immune system. The damage to the immune system by stress, mediated through the hypothalamic–pituitary axis, has been shown to be due to the increase in serum levels of cortisol. In one study, elderly caregivers were shown to have higher cortisol levels and poor antibody response to influenza vaccine.98 The effect of cortisol on immune and other regulatory functions, such as the regulation of blood sugar, dehydroepiandrosterone (DHEA), insulin, testosterone, and bone resorption, flag it as having highly destructive potential. Anxiety, depression, heart disease, AIDS, and osteoporosis have all been linked with elevated cortisol levels. DHEA, another adrenal hormone, is also modulated by stress physiology, although it seems to have the opposite effect of cortisol. High levels of DHEA seem to protect the body from the damaging effects of elevated cortisol. Ratios of DHEA to cortisol are highly predictive of the individual’s ability to tolerate stress.99 Current reviews of the literature relating psychological stress and immune dysfunction support the hypothesis that homeostatic immune mechanisms, both humoral and cellular, are significantly impaired by both natural and experimental stress.5,61,84,100 Hypertension,101 common colds,102 coronary artery disease,103 and myocardial ischemia104 were linked to adverse stress physiology. Stress even has the ability to increase the permeability of the blood–brain barrier.105 The implications of stress-related alterations in the blood–brain barrier expose important insights into enigmatic diseases like chronic fatigue syndrome and stress-induced neurological disorders. 

Endorphins, Hormones, and Neuropeptides …one rapidly activated psychoneuroendocrine mechanism through which a placebo stimulus may reduce both depression and pain is produced by stimulating the endorphin system.18 Research on endorphins is a relatively new area of study in the field of psychoneuroimmunology. Original research by Levine et al.106 suggested that the pain relief noted in placebo studies could be explained by the simple mechanism of endorphin-mediated actions. The original emphasis on endorphins and enkephalins was plausible, considering their known modulation of pain and mood functions. This

TABLE 6.2  Effects of Endorphins on the

Immune System

Immune System Function

Endorphin Effect(S)

Lymphocyte production Chemotaxis T-cell sensitivity to prostaglandin E2 Antibody production Complement T-cell proliferation Natural killer cell function B-cell differentiation

Increased and decreased Increased Increased Increased and decreased Binding of fractions C5B-C9 Modulation of Modulation of Modulation of

position was further supported by later observations that depression increased chronic clinical pain107 and that decreased activity in endogenous opioids may be part of the pathophysiology of depression.108 With the information that placebo can stimulate endorphins, Levine et al.106 believed that an explanation for the action of placebos had finally been found. Furthermore, research showed that an endorphin-mediated, pain-suppressant placebo effect could be abolished with the use of Naloxone, an opioid antagonist.109 The same authors went on to further show that endorphin-mediated placebo effects penetrated other physiological systems besides pain management.110 However, this hypothesis failed to account for the broad spectrum of placebo effects as well as for the fact that the analgesia associated with hypnosis was not affected by an opioid antagonist.111,112 It is important to note that later literature suggested that Levine et al.106 were not entirely wrong in implicating the role of endorphins in the placebo mechanism; rather, these researchers were right for the wrong reason. Endorphins are mainly derived from three precursor proteins (by separate biochemical processes).113 These opioid peptides are released from central and peripheral areas in response to pain, stress, and emotions and perform many physiological functions, of which analgesia is but one.114 However, it is becoming evident that the boundaries between the CNS and the immune system are not as clear as once thought. The several known effects of endorphins on immune system function are listed in Table 6.2.115 When the functions of neurotransmitters such as endorphins are found to have such an intimate relationship with immune integrity, the paradigm of a body with functions performed independently by its parts—a Newtonian type of thinking—begins to lose credibility. To further blur the already hazy distinction between the CNS and the immune system, research demonstrated that endorphins and peptide hormones, such as adrenocorticotropic hormone, thyroid-stimulating hormone, human chorionic gonadotropin, and luteinizing hormone, are produced by lymphocytes.115 It is clear that the demarcation between the CNS and the immune system is impossible to distinguish. The brain and the immune system are the only tissues in the body that have a memory, and the level of communication between the two argues a taxonomy that identifies them as one. Evidence of the innervation of the thymus gland, bone marrow, spleen, and lymph nodes supports the finding that the immune system is subject to efferent CNS information.115 In addition, studies demonstrating the atrophy of the thymus and lymphatic tissues in the absence of growth hormone,116 adrenocorticotropic hormone, and increased steroid production by adrenal cells after interferon stimulation indicate that “in the future it will be difficult to distinguish the receptors and signals that are used within and between the neuroendocrine and immune system.”115 

CHAPTER 6 

BOX 6.4  Six Principles of Optimizing

Placebo Response in Clinical Practice

• Prima non nocerum: Prioritize a hierarchy of therapeutic interventions. • Tollem causum: Remove the obstacles. • Support the therapeutic relationship. • Enhance positive emotional states. • Implement therapeutic conditioning or learning. • Use altered states of consciousness.

CLINICAL APPLICATION Whether a clinician intends to initiate a placebo effect in a clinical setting or not, the mind of the patient will initiate some subliminal healing effects according to the patient’s hope, expectation, conditioning, anxiety reduction, and meaning around the disease and treatment. A recent article in Lancet2 on placebos concluded, “Any ethical assessment of efforts to promote placebo effects in clinical practice first requires knowledge as to the clinical relevance and importance of placebo effects.” A physician with an interest in psychopharmacological treatment, which can be expensive, elaborate, detailed, time consuming, esoteric, and dangerous, usually has considerable knowledge about such treatment. He or she is interested in the symptoms of the patient and the differential response to various drugs and is careful to observe side effects, which may be dangerous. The physician may encourage the patient to call at any time if side effects develop.26 The application of the placebo phenomenon in clinical practice should not be a vague attempt to replace the skill of the medically trained physician with obscure “hand waving,” incantations, and inert lactose pills. In primary care and specialty clinical practice, the physician’s intent should be to optimize patient care by engaging restorative defense mechanisms. To effectively apply current placebo research, the physician must understand several principles (listed in Box 6.4 and discussed here).

Prima Non Nocerum: Prioritize a Treatment Program and Establish a Hierarchy of Care Prima non nocerum is the Hippocratic injunction dictating that a physician care for the patient so that self-healing mechanisms can engage. This ancient phrase means “Do not disturb the organism’s ability to heal itself.” The body must be given the full range of possibilities in allowing the power of homeostasis, vis medicatrix naturae, to have its optimum capability. “Doing no harm” means that a patient is supplied with the level of medical intervention that is appropriate to his or her ability to maintain life support. The job of the physician is to determine when homeostasis or the defense mechanism has lost the ability to respond to disease. Acute traumatic swelling and inflammation and shock are examples of the human defense mechanism responding in a way that threatens the health of the organism. It is most interesting that the organism would make choices, as in shock and inflammation, that could kill it. To practice the principle of prima non nocerum, a physician must learn when to act and when to let the body heal itself. This is the highest art of medicine; each case and situation is different, and it is up to the physician to interpret the needs of the moment. By implication, the physician who seeks to apply this principle understands the principles of physiology on which human life depends for homeostasis. Prima non nocerum does not necessarily mean that a physician withholds invasive therapy: it is the physician’s responsibility to determine when the body is unable to reestablish homeostasis and therapy

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is indicated. If an arm must be severed to save the patient’s life, there is no violation of prima non nocerum. However, to enhance the principle of prima non nocerum, a physician sometimes must withhold therapies and must be content to leave the patient to self-heal. Hippocrates understood the wisdom of letting the body heal on its own, which is implicit in the injunction to “do no harm.” The following account of the treatment of Charles II of England is a case in point117: A pint of blood was extracted from his right arm and a half pint from his left shoulder, followed by an emetic, two physics, and an enema comprised of fifteen substances; the royal head was shaved and a blister raised; then sneezing powder, more emetics, and bleeding, soothing potions, a plaster of pitch and pigeon dung on his feet, poisons containing ten different substances, chiefly herbs, finally forty drops of extract of human skull and an application of bezoar stone; after which his majesty died. When this treatment is compared with modern procedures, such as mammary artery ligation for the relief of angina—a procedure that has no more benefit than sham artery ligation—it appears that physicians continued throughout the centuries to rely on the placebo effect for the care and cure of their patients. Recently, the invasive standard-of-care procedure percutaneous coronary intervention (PCI) of angioplasty and placing coronary stents was shown to be no better than placebo for stable angina. Missing from the medical community discussion on this study was the remarkable fact that some individuals who underwent the sham “placebo” PCI procedure had results that demonstrated that the placebo effect can affect cardiac perfusion.118 Our medical culture has very little interest in exploring the physiological limits of self-healing. Because this effect plays such an important role in health care, simple, noninvasive, and effective treatments should be the goal of all therapeutic approaches. Robert Burton119 wrote in 1628, “an empiric oftentimes, and a silly chirurgeon, doth more strange cures than a rational physician… because the patient puts confidence in him.” The rational physician will also recognize that healing and curing are not necessarily the same. If a patient is helped in any way by the doctor, with or without the use of a placebo, the path of cure has been assisted, although the specific disease may not have responded. Not all patients can be cured, but most patients can be helped. 

Tollem Causum: Remove the Cause of Disease Tollem causum is the principle that seeks to remove the obstacles to cure. The forces “inhibiting the floodgates of health from opening” must be removed for the full force of the patient’s beliefs to effect the path of cure. This concept is fundamental to the philosophy of naturopathic medicine, with its strong emphasis on diet, detoxification, and a pattern of living that is consistent and compatible with the context in which humans evolved. Obstacles to cure block the self-healing capacity of the organism. Contamination with heavy metals and xenobiotics (see Chapter 35), focal infections, electromagnetic pollution, scar tissue, genetic metabolic abnormalities, and parenchymal organ damage defeat the best therapeutic intentions and must be addressed. The patient’s habitat is an important aspect of the therapeutic protocol, not only in the diagnosis and care of internal mental and physiological dysfunction but also in determining which environmental factors may be contributing to dysfunction and disease. These factors might include diet, lifestyle, and living environment. It is of the utmost importance to remove a patient from surroundings that are associated with illness or to assist the patient in creating an environment more conducive to health.

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Factors that provide conditioning that reinforces the disease process can be associated directly or indirectly with one’s environment. For example, if animals are returned to situations where their experimental neuroses were induced, their pathological behavior reactivates.120 When a patient leaves the offending environment to receive treatment from a physician, the prognosis is correspondingly more favorable.17 The physician has the added advantage of a patient’s heightened expectation during an office visit; a patient’s positive associations with the “healing” environment increase his or her receptivity to treatment.121 If the home or work environment is a source of “disease” and an obstacle to cure, providing an alternative environment may be a most helpful way to remove the obstacles to cure. 

Support the Therapeutic Relationship Confidence should surround all aspects of the therapeutic interaction. The patient must have confidence in the doctor’s ability to assist a cure; the doctor must have confidence in the efficacy of his or her therapy122; and there must be an understanding or relationship between the doctor and patient that is mutually conducive to respect, trust, and compassion. The quality of the doctor–patient relationship is paramount. The therapeutic approach to a patient that optimizes the confidence of the patient in the skill of the doctor stimulates the inherent self-regulating healing mechanisms by relaxing the anxiety the patient has about the illness. Anxiety is a well-known immunosuppressant and aggravates the body’s defense mechanisms. An optimum therapeutic relationship, when combined with the clinical skill to remove the cause of homeostatic dysfunction, is the height of therapeutic acumen. As Lewith123 so accurately stated, “The general practitioner may therefore wish to employ all his knowledge, enthusiasm, consultation technique and sympathy, to create the best possible atmosphere in which to elicit a placebo response from the patient.” Current research on factors contributing to the genesis of the placebo effect consistently document the importance of the doctor– patient relationship.124–126 The healing power of the therapeutic interaction has been demonstrated by the commencement of the placebo effect even before the actual administration of the pill.127 The physician facilitates the cultivation of a sound relationship by developing good communication skills. The art of the bedside manner has been recognized throughout history as the primary skill a successful physician needs.128 The history of medicine is as much a history of the relationship between doctor and patient as the evolution of medical technology and techniques. Through centuries in which doctors were doing more harm than good, little more than the esteem of their clientele sustained the medical profession. But however little real help the doctor had to offer, it was to him that people turned when illness struck.129 Bedside manner has been found in clinical studies to entirely alter the course of double-blind studies, and the quality of a therapeutic encounter has been found to facilitate or disrupt the efficacy of a treatment.130 Listening to the patient,130 the verbal and nonverbal communication of the physician, the amount of time spent with the patient,131 patient education,132 the demeanor of the physician,133, and interview skills131 have been suggested as factors and components of effective physician communication skills. Communication between the doctor and patient is not simply a process of one party talking and the other side listening. Deep communication between both sides is a process of “interbrain” synchronization—literally, the brain waves of two people talking begin to match each other, as described in a research study by researchers at the Basque research center BCBL.134 This synchronization or lack of it may be an important aspect of interpersonal communication. The examination of placebo dynamics uncovers the complexity, depth, and importance of the doctor–patient relationship.

Many factors may be responsible for the varying therapeutic effects of the physician–patient relationship. An open-minded investigation of this relationship brings us, incredibly, to the possibility of brain-tobrain coupling, an interconnected matrix of the mind of the healer and the healed.135 Learning to “listen” or synchronize with the patient you are communicating with ensures optimum transfer of information, hope, empathy, and a host of essential dynamics between doctor and patient. Touch is an important form of communication and is sometimes forgotten as a key aspect of the doctor–patient relationship. Highly skilled clinicians with many years of experience, such as the now deceased Dr. John Bastyr (whose remarkable healing abilities inspired the founding of Bastyr University by those privileged to have been his students), frequently impressed upon clinicians the importance of always using diagnostic and therapeutic touch during a patient visit. The doctor’s touch can be diagnostic, therapeutic, and, perhaps most important, a means of communicating that he or she is deeply attuned to the problems, needs, and fears of the patient.133 Touch can heal by increasing tissue mobility and fluid exchange, as in massage, or by relieving pain, as demonstrated by research on healers who use their hands.136 Touch has also been documented in well-designed double-blind research to extend an unusual healing power that can be transmitted through the hands to plants and animals.137 Among other methods of enhancing confidence between the doctor and patient, the setting in which a doctor provides therapy to a patient also determines its effectiveness. The doctor’s office setting is very important for optimum and effective treatment: tools and support systems are more accessible, and a heightened patient response results from seeking out the “healing” environment. In a clinical trial with hypertensive patients, placebo alone was not as effective as when it was administered in conjunction with hospitalization. The visit to the physician represents a search for changes that cannot be found through “self-care” or over-the-counter medicines. According to Frank138: In short, it appeared that the placebo situation relieved chiefly anxiety and depression, that the degree of relief was unrelated to personality and autonomic measures, and that the patients who responded strongly to a placebo at one time might not at another. In conjunction, these results suggest that the extent of responsiveness to a placebo depends on the interaction of the patient’s state at a particular time with certain properties of the situation. The finding that administration of tests and questionnaires seemed to have at least as beneficial an effect as had the pill implies that any interaction between patient and situation that heightens expectations of help may lead to symptom reduction and improvement in mood. The aspects of the situation producing this effect include not only presentation of a symbol of the physician’s healing powers (a pill), but any attention and interest shown by professional personnel. This phenomenon was also observed in industry and termed the Hawthorne effect. As a direct result of the greater attention factory workers received during investigation, the quality of their work improved.139 In conclusion, the importance of a doctor–patient relationship and the confidence that it engenders shows that all human beings need to share their feelings and experience the therapeutic benefits of touch: the doctor–patient relationship provides an ideal way to meet these fundamental needs. 

Enhance Positive Emotional States Love in all its subtleties is nothing more, and nothing less, than … the psychical convergence of the universe upon itself. —Pierre Teilhard de Chardin, The Phenomenon of Man

CHAPTER 6  For optimum enhancement of the psychoneuroimmune system, the physician must assist the patient in developing practices that amplify positive emotional states and reduce a negative emotional state. A negative mental state (anxiety, stress, panic, anger, depression, neurotic behavior, self-deprecation, self-destructive feelings and tendencies, and a weak will to live) hinders the ideal functioning of the psychoneuroimmune endocrine axis, disrupting homeostasis. Engle140 termed this the giving-up/given-up complex: Study of the life settings in which patients fall ill reveals that illness is commonly preceded by a period of psychological disturbance, during which the individual feels unable to cope. This has been designated the giving-up/given-up complex and has the following five characteristics: a feeling of giving up, experienced as helplessness or hopelessness; a depreciated image of the self; a sense of loss of gratification from relationships or roles in life; a feeling of disruption of the sense of continuity between past, present, and future; and a reactivation of earlier periods of giving-up. It is proposed that this state reflects the temporary failure of the mental coping mechanisms with a consequent activation of neurally regulated biologic emergency patterns. Changes in body economy so evoked may alter the organism’s capability to deal with concurrent pathogenic processes, permitting disease to develop. The importance of reducing negative mental states in acute and chronic conditions has been discussed extensively.70 Acute psychological stress is documented to cause various forms of cardiopulmonary dysfunction and even death.61 Chronic mental and emotional strain causes a breakdown of the immune system and can lead to disease. The homeostatic processes become overwhelmed by autoimmune, microbial, or neoplastic invasion. Major writers on the subject of acute and chronic stress emphasize the high priority of managing the physiologically and immunologically destructive effects of the human body’s response to stress. Pelletier141 listed hypertension, arteriosclerosis, migraine headache, cancer, chronic bronchitis, emphysema, asthma, and arthritis as disease processes that are caused or exacerbated by stress physiology. A study researching the relationship between resistance to streptococcal infections in families and stress load in the family found a positive correlation.142 Another study on the psychosomatic susceptibility to infectious mononucleosis found that two psychosocial factors, high motivation and poor academic performance, significantly increased the risk of “disease” infection.143 In still another, anticipation of mood and menstrual discomfort were positively correlated and manipulated, thereby supporting the suspicion that expectations act as a determinant of mood.144 The conclusion that there is no acute, chronic, or degenerative disease that is not affected by a patient’s mental and emotional state must be drawn from the pervasive immunoendocrine effects generated by the mind and emotions. Wolf145 and Cousins146 wrote of the power of panic as a factor in myocardial infarction; Marbach et al.107 described depression as a component in myofascial pain dysfunction; and Shekelle et al.147 noted, in a 17-year follow-up study, a twofold increase in the incidence of cancer in depressed patients. The clinical scenarios these observers described imply that the placebo effect can control the onset and advance of a disease by shutting down the destructive thoughts, images, and feelings that mediate stress. Enhancing positive emotions is the corollary of controlling the damaging effects of negative mental and emotional states. Laughter,23 hope,148 acceptance,64 and the reduction of suffering149 have been shown to speed the course of healing and reduce the level of pain and distress reported by patients. Although pain is sometimes the only

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language nature can use to adequately communicate to the patient that something is in need of healing, “the relief of suffering and the cure of disease must be seen as twin obligations of a medical profession that is truly dedicated to the sick.”149 Acceptance has been observed to be a key factor that assists patients in better understanding their pain.64 Acceptance does not mean complacency in the face of disease but a rational understanding of the situation and the limitations that can sometimes accompany a disease process. The importance of cultivating hope in a patient also cannot be underestimated.150 The fact that a patient seeks the help of a physician or “caregiver” already implies a substrate of hope and is a signal that the patient can visualize the potential for recovery. The treatment needs to merely stimulate this willingness to envision a future of health. Hope is an embodiment of the patient’s and the doctor’s ability to visualize an image of healing and recovery. This process is a recurrent theme in imagery therapy,151 visualization therapy,152 therapeutic touch,153 and psychic healing.154 Hope is both an active and a passive placebo. The passive hope placebo is that which is brought with the patient as the act of seeking help generates a level of unspoken faith in an image or potential for cure. The active hope placebo is generated by the physician, who consciously instills a vision or image of cure in the patient as an adjunct to therapy. Frank138 performed a double-blind study in which patients were divided into control and induction groups. The induction group was led through a process whereby their hope was strengthened to conform with the expectations of the therapist138: It introduces some perceptual clarity into the process of treatment; and to the extent that all our therapists adhered roughly to the insight model of therapy, it helped to bring the patient’s expectations in line with what actually occurred in treatment, and also helped him behave in accordance with the therapist’s expectations of a good patient. The induction group was actually being consciously strengthened to a level of optimal response but was not being led into false expectations.155 This type of patient education or active placebo is a necessary and useful tool for framing and directing a positive outlook and prognosis. If a patient can conceive of a state of wellness, then that state of wellness can be achieved. It is the job and domain of the physician to discover those images, emotions, and perceptions that reside in the conscious and subconscious mind of the patient that block the image of a positive state of health. He or she must actively work to control these with the same level of intent as with any presenting gross complaint or physiological dysfunction. Finding these dysfunctional mental substrates and working with the patient to try to change them is fundamental to treating the true cause of disease (see earlier discussion of tollem causum). Research demonstrated the importance of positive and negative thinking in heart disease and cancer, the two areas of disease that cause the highest death rate. Doctors’ health care management protocols should reflect this research in the same way that attention to a proper diet is part of a management approach to high serum cholesterol. It is now clearly established, for instance, that even low levels of stress trigger the onset of myocardial ischemia.156 We also know from the work of Steven Greer157 and David Spiegel158 that attitude and emotional exploration are critical to breast cancer survival. Knowing these scientific facts, all doctors must have strategies for helping their patients explore the areas of stress management, group therapy and support groups, and skills in building positive attitudes. 

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Implement Therapeutic Conditioning or Learning Those who remain at least dimly aware that everything they say or do to a patient conveys a major or minor, positive or negative, and helpful or harmful psychological impact are likely to be more effective physicians.159 Conditioning of the mind has been suggested as a mechanism by which the placebo effect becomes a learned response.17,19,138 The future of the therapeutic application of placebo will probably hinge primarily on the use of conditioning. A doctor who can understand this will pay close attention to the stimuli of his or her patients and modify these stimuli in a scientific way to help treat immune-related and neurologically related diseases. Modern psychology acknowledges two models of conditioning or reinforcement of learning behavior, operant and classical. Operant conditioning is a behavior response that theoretically occurs in the presence of some stimulus that is a positive reinforcement; for example, a rat will learn to press a conditioning bar if a food pellet is dispensed as a result. Classical conditioning is a behavior response created by the simultaneous pairing of unconditioned and conditioned stimuli before an evoked response. This is best illustrated by the experiments of Pavlov and his “salivating dog.” In Pavlov’s experiment with the conditioning of a dog’s salivary response to the ringing of a bell, the bell ring is the conditioned stimuli, and the food is the unconditioned stimuli. The salivation is the unconditioned response to the food that becomes the conditioned response. When the dog finally associates the bell ring with the food, the ringing alone causes salivation, the conditioned response. The principle of classical conditioning has far-reaching implications for the diagnosis and treatment of disease because of the pervasive and permeating implications that conditioning has in all the sensory stimuli of daily existence, in sickness and in health: “Pavlov’s teachings, concepts and basic notions afford the real and ultimately scientific basis for the recognition of the potentialities of medical science attacking diseases from both the psychic and somatic sides.”160 For the purposes of this discussion, one must recognize that classical conditioning happens randomly in our environment and is closely linked to health and healing phenomena. Subconsciously, we note random events and associate them with previous events and observations, independent of an intended learning behavior. Operant conditioning happens in the context of reward, and classical conditioning happens in the context of associated stimuli. There is a much greater predominance and range of associated stimuli for classical conditioning than for operant conditioning for the genesis of the placebo effect. This is because the operant depends on reward, although operant conditioning can happen in the medical model: “Pain-killing drugs that I have taken in the past kill pain; therefore this capsule, which is a painkiller, will kill my pain.” Gliedman et al.17 noted that drugs that affect the CNS are readily conditioned, whereas drugs that affect the peripheral nervous system and are secretory stimulators (e.g., atropine and pilocarpine) do not result in the establishment of a conditioned response. The primary importance of psychological states to CNS excitation demonstrates that the pivotal loci of command for conditioning reside within the hypothalamus and the limbic system. Therefore a doctor who can induce a state of central excitation in the patient can encourage and condition the patient to make those changes that are deemed necessary for the recovery of health. The conditioning of a patient to a placebo response is modified by learning stimuli associated with the illness, the stimuli of the doctor and the therapeutic setting, the stimuli of the therapy, previous health, medical therapy, and authority-related experiences.161 The way that all

of these factors interact in the psyche of the patient determines the nature of the placebo response that is achieved. Satiation obscures the conditioned response, whereas situations of increased stress seem to potentiate the responsiveness of the placebo effect.64 The placebo effect, conditioning, and learning may therefore be subject to the nature of central excitatory states as well as levels of stress and distress. The physiological breadth of the placebo response in humans can now be understood in terms of the variety of interactions and effects that drugs, therapeutic procedures, and sensory phenomena of the medical environment have on the psychosomatic matrix of a patient’s consciousness. Rossi19 noted that this complicated web of sensory processing reveals how any facet of therapy “that alters any aspect of the body’s sensory, perceptual or physiologic responsiveness on any level can disrupt the more or less fragile state-dependant encoding of symptoms and thereby evoke a ‘nonspecific’ but real healing effect that we call the placebo response.” The scientific basis of therapeutic applications of psychoneuroimmunology is based on classical conditioning. Ader and Cohen162 performed research to show that the immune system could be conditioned for therapeutic purposes. They conditioned immunosuppression in rats by injecting them with a conditioned stimulus of cyclophosphamide (a potent immunosuppressing agent) while feeding them a saccharine solution as an unconditioned stimulus.162 The idea of conditioning for immunomodulation in human patients is therefore a promising therapeutic modality. Applying conditioning techniques for the treatment of systemic lupus erythematosus involving a dosage that normally had minimal results resulted in a delay in the development of the disease.163 To fully account for the extent of previous and future conditioning in a patient, the physician must take a complete and exhaustive history to explore the influences of family, work, accidents, emotional predispositions, medical history, and neutral stimuli as contributing factors during the onset of an illness. Lifestyle and emotional, behavioral, or physiological factors might contribute to maintaining the state-dependent learning pattern of disease and dysfunction or give clues to a successful therapeutic intervention. A good example of this is the demonstration by Batterman and Lower164 of increased analgesic effectiveness based on similar previous therapy. A physician who knows which therapies succeeded and which failed can take advantage of the patient’s conditioning and encourage biochemical pathways that the body has learned. Drug or therapeutic interventions are not procedures that can be predicted in the same way that in vivo experimental results can. The variables involved in human responses to therapy are clearly underestimated in the current rush of research-oriented therapeutic evaluation.165 Therefore a patient who has been treated by a number of physicians or practitioners for a complaint and has received no results or relief has been conditioned to believe that consultation and treatment by a physician will provide no positive changes. When the patient visits the next practitioner, even if this practitioner can offer a diagnosis and treatment that are correct answers to the long-sought cure, there are very real patient conditioning factors that must still be considered. Consider the case of a young woman who underwent treatment for breast cancer and the clinical course of the ensuing metastases. Each time she had a positive response to therapy, she experienced a subsequent remanifestation of the cancer. The result of this conditioning was that she came to equate each new course of chemotherapy as a herald of some new manifestation: she “was torn between a desire to live and the fear that allowing hope to emerge again would merely expose her to misery if the treatment failed.”166

CHAPTER 6  The parameters of conditioning in a clinical setting extend to all aspects of the patient’s sensory perceptions. Consciously or unconsciously, the physician provides an environment for patient learning. Lipkin167 pointed out that every drug, every apparatus, every injection, and every piece of information or advice carries a suggestion of help and hope, regardless of the physiological effects that may accompany it. The physician must realize that patients are taking in all the information about the surroundings, interactions, and therapy and are making associations that can potentially affect the course of their responsiveness to therapy. Mowrer86 observed that the “safety signals” of syringes, laboratory coats, and behavioral procedures were all retained in the patient’s psyche for future association. A physician can skillfully take advantage of these signals by encouraging and cultivating response generalization or by associating previous therapeutic situations with subsequent treatments by means of unconditioned stimuli, such as office music, odors, and images. Giving patients some sort of unconditioned stimulus that can be taken home allows them to associate with the conditioned response, eliciting the memory of the therapeutic interaction while patients are away from the doctor’s office. These unconditioned stimuli or placebos can be given in multiples at one time81; changed for more powerful stimuli168; and delivered at the end of an induction, suggestion, or imagery procedure. They should not be limited to pills or other apparent medicaments and should extend to sounds, smells, visualizations, and feelings. It should be remembered that therapeutic conditioning depends on a perceived physiological shift or change in the patient as described in the theory and research of biofeedback.169 This shift can be experienced as a sense of relaxation, increased warmth or circulation, altered autonomic tone, or a change in some sensory perception. Patients know immediately when there is no change in their disease or dysfunction after they have been given placebo.170 Therefore some patients need a more active form of therapeutic management that allows for some level of perceived change. Ideally this perception would be a sense of being free from pain or alteration from a state of abnormal physiological function to a state of improved physiological function. Acupuncture, spinal manipulation, drug therapy, physiotherapy, hydrotherapy, and surgery are all therapies that can create an immediate biochemical effect that is perceived by the patient. The optimum model to apply to the concept of conditioning therapy and the selection of an appropriate therapy or modality was proposed by Greene and Laskin171 in their evaluation of myofascial pain dysfunction. During an 11-year follow-up study of patients with myofascial pain dysfunction, these researchers concluded that when comparing the effectiveness of a wide variety of reversible and nonreversible (surgical) therapies, conservative and reversible therapies were the most important and appropriate treatment factors for the patient’s health and well-being. Focusing on patient communication, educating patients about the reversibility of the condition and the nature of muscle dysfunction as it relates to stress–pain–spasm, developing a therapeutic strategy based on increasing patient awareness and self-management skills, and selecting a flexible treatment strategy were all found to be essential for achieving a good initial response that could lead to long-term wellness. Greene and Laskin171 believe that the specifics as to which therapy is most indicated are not as important as the need to focus on the nature of presenting musculoskeletal problems and the factors and complexity of the treatment environment. The routine use of active pharmacological substances reinforces the relationship between conditioned and unconditioned stimuli. However, the routine use of unconditioned stimuli in the absence of a conditioned response weakens the therapeutic efficacy of the practitioner and has been described as “placebo sag.”18 Therefore the

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learning of a conditioned response from unconditioned stimuli could diminish if the conditioned stimuli fail to produce an adequate or reliable conditioned response. Without the intermittent demonstration of active strength, the placebo effect will get weaker and weaker. The implications of placebo sag for practitioners of alternative medicine, who try to work with the body’s own defense mechanisms without overwhelming medical intervention, are that periodic use of perceptually active therapy is needed to support a patient who is not able to respond or responds too slowly to a gentler therapeutic nudge. In this case the physician must recondition the vital force to open a path to homeostasis. In a sense, this may be a paradigm of the therapeutic situation, in which changes toward health are induced in the patient by a doctor who is able to cultivate a basic state of arousal, presumably central in nature. This state of arousal causes the patient to become accessible to the doctor’s expectations of the patient.17 The typical placebo burst, in which a therapy is initially effective after a short period but then wanes, is now understood in terms of the placebo sag from a lack of effective unconditioned stimuli to maintain the conditioned framework.168 Physicians who lack the ability to extract themselves from a series of unsuccessful therapies risk eventual placebo sag18: [T]herapists who primarily use their active strengths (or unconditioned stimuli) paradoxically will get stronger placebo effects than quacks, will enjoy escalating credibility, and will seem as miracle men—when in fact perhaps only half their miracles can be traced to their active ingredients while the other half is a function of the anticipatory (or conditioned) response elicited by their conditioned features. Because the visit to a physician is often initiated by the physical pain of the patient, it stands to reason that skillful pain management is a high priority in establishing a therapeutic conditioned response. Pain management by hypnosis, transcutaneous electrical nerve stimulation, therapeutic touch, direct or indirect manipulation, imagery, acupuncture, meditation,172 and an understanding that aims to elicit the nature of suffering166 can all be valuable therapeutic adjuncts to establishing a therapeutic environment that conditions the patient for the full potentiation of his or her healing capabilities. (See Chapter 42 for a full discussion of these techniques.) With the recent development of standardization of, research into, and concentration of the active components of plant medicines, vitamins, and biochemical precursors, naturopathic medicine and other forms of alternative medicine stand on a stronger therapeutic base because of an ever-growing verification of the pharmaceutical and therapeutic armamentarium. These therapeutic modalities are characterized by safe yet physiologically active substances and procedures; therefore they provide some defense against placebo sag. 

Use Altered States of Consciousness Since ancient times, aboriginal humans have recognized the tremendous therapeutic power that lies dormant in the subconscious mind. For thousands of years, shamans and medicine men have used trance states to engage the most subtle aspects of the patient’s subconscious to affect factors in disease pathogenesis and prognosis.173 In modern medicine, it has been documented that shamanistic healing involving altered states can offer dramatic “spontaneous remissions33;” the mechanisms of this process have been explored in the theory and application of hypnosis.4,76 Most currently accepted techniques employed to trigger the subconscious to effect positive changes in somatic or psychic health involve hypnosis. The placebo effect has been linked with hypnosis, or

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“low arousal states,” which are therefore believed to be critical factors in the evaluation of the mechanisms and perimeters of placebo.160 A review of the literature documenting the potency of hypnosis and the observed results of placebo clearly demonstrated that these two areas yielded remarkably similar clinical results. The inquiry into hypnosis grew out of the simple intent to validate the effectiveness of the mind in healing processes, whereas most placebo literature grew out of the intent to demonstrate a certain percentage of chance, fluke, spontaneous remission, or psychosomatic illness as a factor to be ruled out in the delivery of intelligent, scientific health care. Using these antiquated definitions of placebo and hypnosis, one is led to believe that hypnosis describes a process of healing based on the skillful guidance of a qualified practitioner and that placebo describes a process based on chance, regardless of the professional circumstances. On closer inspection, the distinction between the two blurs: they appear to be much the same process. Illness, healing, and health states shift constantly in the homeostatic system, a system that is affected by stimuli received through the different levels of awareness and can be accessed, investigated, and modified by a variety of techniques. These include placebo, hypnosis, and induced altered states of consciousness. Rossi19 noted that because memory depends on and is limited to the level of awareness in which the memory was acquired, it is “state-bound information”: State dependent memory, learning, and behavior phenomena are the missing link in all previous theories of mind body relationships.… The major thrust of these hypotheses is that mind-body information and state-dependent memory, learning and behavior mediated by the limbic-hypothalamic system, are the two fundamental processes of mind-body communication and healing.… The new approach to mind-body healing and therapeutic hypnosis may be conceptualized as processes of accessing and utilizing state-dependent memory, learning and behavior systems that encode symptoms and problems and then reframing them for more integrated levels of adaptation and development. Some psychosomatic phenomena are coded into the behavior of an individual through state-induced patterning. Until the patient can access the state in which somatic complaints are induced, possibly through hypnosis or other methods that break the sympathetic dominance of “encoded” shock,174 the psyche cannot clear them from the soma19: A person in a traumatic car accident experiences an intense rush of the alarm reaction hormones. His detailed memories of the accident are intertwined with the complex psychophysiological state associated with these hormones. When he returns to his usual or “normal” psychophysiological states of awareness a few hours or days later, the memories of the accident become fuzzy or, in really severe cases … the victim may be completely amnesic. The memories of the accident have become “state-bound”—that is, they are bound to the precise psychophysiological state evoked by the alarm reaction, together with its associated sensory-perceptual impressions. In accessing these psychosomatic state-dependent areas of homeostatic dysfunction, the physician must use techniques that relax the conscious mind and allow access to subconscious content for reframing. The nature of the visit to a physician encourages a patient into more accessible unconscious states, as demonstrated by higher placebo effects when patients present in a hospital setting.121 These labile states of consciousness are quite natural; humans constantly cycle in and out

of different consciousness states.121 These cycles, or ultradian rhythms, are described as alternating cycles of hemispherical dominance that change every 1½ hours. When these cycles are interrupted by behavioral stress, psychosomatic behavioral responses such as ulcers, gastritis, asthma attacks, and rashes develop.175 A change in these rhythms manifests as a period of psychic repose. If an individual is in the midst of performing a task, daydreaming or the perceived need for a rest or coffee break may be the external manifestation of an internally sensed signal of a change in rhythm. This is also a period when one is highly susceptible to hypnotic suggestion. Because these rhythms are very flexible and labile, they can be invoked through hypnosis, or if the physician senses a natural lull indicating a hemispherical switch, a “natural” trance can be induced. Centuries ago in India, practitioners of hatha yoga observed the effect of mental states on the breathing patterns of an individual. With anger, frustration, and mental instability, the breath reflects a short, arrhythmic pattern that mirrors the disturbed psyche of the person. Conversely, when a person is in a peaceful, relaxed, deep meditative state, the breath is long, rhythmic, and barely perceptible. Their discovery formed the basis for the development of breathing exercises called pranayama (literally, regulation or restraint of the vital energy), which aimed to calm the breath so that deep states of meditation and focused concentration could be attained. Current research has affirmed the powerful effect these exercises have on asthma, diabetes, chronic gastrointestinal disorders, and psychosomatic and psychiatric dysfunction.176 Traditional literature on the ethnomedical effects of training the mind and energy (prana, qi, ki, lung) in India, China, and Tibet consistently remark on the antiaging effects of these training methods. Research suggests that meditation may have a deep antiaging response on human functioning, potentially measurable in the epigenetic aging effect.177 Therapeutic exercises that use somatic stimuli to effect changes in the psyche create fertile environments for stimulating the placebo response. A breathing technique used to decrease sympathetic tone or alter nostril predominance for causing shifts in hemispherical activity,178 an exercise to release fascial muscle tension and thereby effect mood-enhancing blood flow in the brain,179,180 and a biofeedback treatment that aids in slowing the heart rate and decreasing negative emotional states169 are all examples of how the psyche can be accessed by the soma. The whole process of eliciting the placebo response involves an attempt to marshal all the reserves and potential for healing through a doctor–patient interaction, engaging both the patient’s mind and body to reestablish homeostatic equilibrium. Therapeutic meditation training has shown benefit in modifying pain.181 Engaging in a formal or traditional method of meditation training may give the patient enhanced insight into the nature of his or her mind and thereby elicit psychological and physical health benefits.182 Trained meditators exhibit unique abilities of mental functioning.183 Medical applications of mind-training methods might be better served by relying on methods with deep cultural experience, at the expense of adopting a liberal, nondenominational, nonsectarian method of “relaxation therapy,” as it appears not all awareness therapies are created equal. Traditional meditation-training methods offer the possibility of sustained and enhanced awareness of mental states, which may contribute to positive medical outcomes.184 Healthcare professionals can use the wisdom of psychosomatic therapies as a central part of their therapeutic protocol. In addition to the specific therapeutic regimen, treatment of the whole patient can be achieved through these harmonious techniques. If physicians could persuade patients to care daily for their emotions, minds, and spirits

CHAPTER 6  the way they care for their hair or teeth, the effectiveness of any prescribed treatment would be greatly enhanced. As a primary therapeutic adjunct and important basis for preventive medicine, this line of treatment is all too often ignored. 

ETHICS There are two forms of “conscious” placebo use by the physician. The use of a placebo as a gentle therapeutic agent by a practitioner is very different from the use of a placebo in a controlled trial in which the possibility of a known therapy is withheld in a treatment group. Some researchers believe that the use of placebos in clinical trials breaches the Declaration of Helsinki, which states that every patient should be assured of the best proven diagnostic and therapeutic method.185 The ethical problems of delivering health care in a research design in which there is a possibility of a favorable outcome, and half of the group is denied access to this possible favorable outcome, make it a troubling issue. The ethical use of placebos has also been questioned in an attempt to determine whether a physician should be deceiving patients during the process of healing.186 Although some writers advocate a restricted use of pure and impure placebos because of their “deceptive” nature,169 it becomes clear in a brief review of the current literature6 that any argument for or against the use of placebo assumes the existence of medical procedures that are free of a potential placebo effect. Brody29 concluded that a placebo can be called the “lie that heals.” However, closer examination shows that it is not the lie that does the healing but, rather, the relationship between the patient and doctor that stimulates a natural self-healing mechanism via psychological, symbolic, and biological intervention29: For some time, medical science has looked almost exclusively at technical means of diagnosis and treatment; the doctor/patient relationship that forms the setting for their application has been naively viewed as a noncontributory background factor, relegated to the amorphous realm of the “art of medicine,” or simply ignored. In this setting, the placebo effect has inevitably been viewed as a nuisance variable, interfering with our ability to elicit “clean data” from clinical trials; and deception in medicine has been seen either as an unimportant side issue or as a tolerated means toward an end. But as the doctor/patient is rediscovered as a worthy focus for medical research and medical education, the placebo effect assumes center stage as one approach to a more sophisticated understanding of this relationship. A physician’s correct understanding of the nature of placebo therapy has been observed as able to coexist with its inaccurate use and

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abuse.41 It has been recommended, however, that (1) a pure placebo should not be prescribed unless the physician has examined the exact indications even more carefully than when prescribing specific therapy, and (2) to avoid missing a disease process that can be easily treated with an empirically proven protocol (e.g., vitamin B12–deficient peripheral neuropathy), the physician should not relax a diagnostic protocol because a patient seems to be responding to a placebo.186 The final ethical hurdle of placebo use, or any medical treatment, for that matter, is the abuse of hope in the patient’s path of healing. It is one thing to make a harmless recommendation that provides no therapeutic value, but it is another to subject a patient to the known consequences of a dangerous procedure in the pursuit of a dubious outcome. Hope can be abused, leading the patient to experience unreasonable suffering.187 

CONCLUSION Health practitioners must be equipped with a better understanding of placebo therapeutics.10,188 For many years now, the study of placebos has been recommended to doctors and other healthcare professionals. The ideal environment for the dissemination of the therapeutic implications of the doctor–patient relationship is in medical schools as a required part of the curriculum. After finding a pattern of misuse and misunderstanding about the nature and efficacy of placebo, Goodwin et al.41 recommended that better education might result in more effective placebo use. In 1938 Houston128 wrote of the need to reaffirm the art of medicine because he perceived a trend in medicine that invested in a concept of the therapeutic doctor–patient interaction as “undisciplined thought.” Houston’s remedy for the intellectual bias that viewed medicine as a “tight, fast-set science” was to emphasize the importance of psychobiology in medical schools129: One of the most hopeful moves in medical education is teaching to first-year students the elements of psychobiology. A system of belief is implanted best in the young. It would be my suggestion that psychobiology be taught in the premedical years, that the doctor/patient relationship be the beginning of medical studies. A deep insight into this fundamental philosophy is a chief concern of the internist.

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7 Positive Mental Attitude John Nowicki, ND, and Michael T. Murray, ND

OUTLINE Introduction, 102 Effect of Attitude, Personality, Emotions on Health, 102 Longevity, 102 Immune Function, 102 Cardiovascular Health, 103

INTRODUCTION A positive mental attitude is one of the foundational elements of good health. This axiom has been contemplated by philosophers and physicians since the time of Plato and Hippocrates. Attitude is reflected by explanatory style, a term developed by noted psychologist Martin Seligman to describe a cognitive personality variable that reflects how people habitually explain the causes of life events.1 Explanatory style was used to describe individual differences in response to negative events during the attributional reformulation of the learned helplessness model of depression developed by Seligman (described in Appendix 12). The Attributional Style Questionnaire developed by Seligman or the Revised OptimismPessimism (PSM) scale of the Minnesota Multiphasic Personality Inventory (MMPI) can be used to determine an individual’s level of optimism. In addition to simple conventional wisdom, modern research has also verified the important role that attitude—the collection of habitual thoughts and emotions—plays in determining the length and quality of life. Specifically, studies using various scales to assess attitude, including the PSM scale of the MMPI, have shown that individuals with a pessimistic explanatory style have poorer health, are prone to depression, are more frequent users of medical and mental health care delivery systems, exhibit more cognitive decline and impaired immune function with aging, and have a shorter survival rate compared with optimists.1–8 One study involved a large cohort of 5566 people who completed a survey at two time points, aged 51 to 56 years at time 1 and aged 63 to 67 years at time 2. This survey included a questionnaire to determine positive psychological well-being by measuring self-acceptance, autonomy, purpose in life, positive relationships with others, environmental mastery, and personal growth. The results showed that people with low positive well-being were 7.16 times more likely to be depressed 10 years later.9 This research highlighted the fact that although life is full of events that are beyond one’s control, people can control their responses to such events. Attitude plays a significant role in determining how people view and respond to the stresses and challenges of life. 

102

Self-Actualization, 103 Clinical Application of Learned Optimism, 104

EFFECT OF ATTITUDE, PERSONALITY, EMOTIONS ON HEALTH Longevity In 1981 the Leisure World Cohort Study undertook a prospective cohort study of nearly 14,000 elderly women and men in a California retirement community to study the relationship between mental attitude and longevity and successful aging.10 Participants completed a postal survey including seven positively worded items from the Zung self-rating depression scale and were followed to death or December 31, 2016 (a 35-year span), whichever came first. In both men and women, a more negative attitude was associated with significantly higher mortality. The risk of death significantly increased by 2% (women) and 4% (men) for each unit decrease in total attitude score. Overall, the multivariable-adjusted hazard ratio (HR) for death for individuals in the lowest versus the highest quarter of total attitude was 1.24 (1.16–1.32) for women and 1.30 (1.19–1.41) for men. Thus strategies to improve mental outlook may help improve the quantity as well as the quality of life. 

Immune Function The importance of attitude to human health has been examined in the links among the brain, emotions, and the immune system. Research in the field of psychoneuroimmunology indicates that every part of the immune system is connected to the brain in some way, either via a direct nervous tissue connection or through the complex language of chemical messengers and hormones. What scientists are discovering is that every thought, emotion, and experience sends a message to the immune system that either enhances or impairs its ability to function. A simplistic view is that positive emotions, such as joy, happiness, and optimism, tend to boost immune system function, whereas negative emotions, such as depression, sadness, and pessimism, tend to suppress it. Studies examining immune function in optimists versus pessimists have demonstrated significantly better immune function in the optimists. Specifically, studies have shown that, compared with pessimists, optimists have increased secretory immunoglobulin-A function, natural killer cell activity, and cell-mediated immunity, which is demonstrated by better ratios of helper to suppressor T-cells.6,11–14

CHAPTER 7  The immune system is so critical to preventing cancer that if emotions and attitude were risk factors for cancer, one would expect to see an increased risk of cancer in people who have long-standing depression or a pessimistic attitude. Research supports this association; for example, smokers who are depressed have a much greater risk of lung cancer than smokers who are not depressed.15 Depression and the harboring of other negative emotions contribute to an increased risk of cancer in several ways. Most research has focused on the effect of depression and other negative emotions on natural killer cells. Considerable scientific evidence has documented the link between a higher risk of cancer and negative emotions, stress, and a low level or low activity of natural killer cells.16 Negative emotions and stress paralyze many aspects of immune function and literally can cause natural killer cells to burst.16,17 Furthermore, the prototypical cancer personality—an individual who suppresses anger, avoids conflicts, and has a tendency to have feelings of helplessness— has lower natural killer cell activity than other personality types.13,14 These studies also indicate that individuals with a personality type that is prone to cancer have an exaggerated response to stress, which compounds the detrimental effects stress has on natural killer cells and the entire immune system. Depression and stress not only affect the immune system but also appear to hinder the cell’s ability to repair damage to DNA. Most carcinogens cause cancer by directly damaging DNA in cells, thereby producing abnormal cells. Some of the most important protective mechanisms against cancer in the cell’s nucleus are the enzymes responsible for the repair or destruction of damaged DNA. Several studies have shown that depression and stress alter these DNA repair mechanisms. For example, in one study, lymphocytes from depressed patients demonstrated impairment in the ability to repair cellular DNA damaged by exposure to x-rays.18,19 Just as research has identified personality, emotional, and attitude traits that are associated with impaired immune function, the field of psychoneuroimmunology has likewise identified a collection of “immune power” traits that include a positive mental attitude; an effective strategy for dealing with stress; and a capacity to confide traumas, challenges, and feelings to oneself and others.16,20 

Cardiovascular Health The cardiovascular system is another system intricately tied to emotions and attitude. The relationship of an optimistic or pessimistic explanatory style with the incidence of coronary heart disease was examined as part of the Veterans Affairs Normative Aging Study, an ongoing cohort study of older men.8 These men were assessed by the MMPI PSM scale. During an average 10-year follow up, 162 cases of incident coronary heart disease occurred: 71 cases of incident nonfatal myocardial infarction, 31 cases of fatal coronary heart disease, and 60 cases of angina pectoris. Men reporting high levels of optimism had a 45% lower risk for angina pectoris, nonfatal myocardial infarction, and coronary heart disease death than men reporting high levels of pessimism. Interestingly, a clear dose–response relationship was found between levels of optimism and each outcome. To illustrate how closely the cardiovascular system is linked to attitude, one study showed how measures of optimism and pessimism affected ambulatory blood pressure.21 Pessimistic adults had higher blood pressure levels than optimistic adults, suggesting that pessimism has broad physiological consequences. Affective well-being (happiness and pleasure) and eudaimonia (sense of autonomy and purposeful engagement with life) have been associated with smaller waist circumference, healthier lipid profiles (e.g., greater high-density lipoprotein cholesterol [HDL-C], lower levels of triglycerides), higher levels of

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Being Needs Self-actualization

Self-esteem Needs Belonging Needs Safety Needs Physiologic Needs Deficit Needs Fig. 7.1  Maslow’s hierarchy of needs.

serum antioxidants, and lower levels of inflammatory markers (e.g., C-reactive protein [CRP], fibrinogen).22 Excessive anger, worrying, and other negative emotions have also been shown to be associated with an increased risk for cardiovascular disease; however, these emotions may simply reflect a pessimistic explanatory style. 

SELF-ACTUALIZATION A physician’s role should include facilitating the health of the patient as well as helping the patient achieve self-actualization, which is a concept developed by Abraham Maslow, the founding father of humanistic psychology. His work and theories were the result of more than 30 years of intense research on psychologically healthy people. Essentially, Maslow was the first psychologist to study healthy people. He strongly believed that the study of healthy people would create a firm foundation for the theories and values of a new psychotherapy. Maslow discovered that healthy individuals are motivated toward self-actualization, a process of “ongoing actualization of potentials, capacities, talents, as fulfillment of a mission (or call, fate, destiny, or vocation), as a fuller knowledge of, and acceptance of, the person’s own intrinsic nature, as an increasing trend toward unity, integration, or synergy within the person.”23 Maslow developed a five-step pyramid of human needs in which personality development progresses from one step to the next. The needs of the lower levels must be satisfied before the next level can be achieved. When needs are met, the individual moves toward well-being and health. Fig. 7.1 displays Maslow’s hierarchy of needs. The primary needs that form the base of the pyramid are basic survival or physiological requirements: the satisfaction of hunger, thirst, sexuality, and shelter. The second step consists of safety needs, which are essential for dealing with the world: security, order, and stability. The individual then progresses to the third step, which involves the ability to love and be loved: belonging. The fourth step involves self-esteem and self-respect: approval, recognition, and acceptance. The final step is self-actualization: the use of one’s creative potential for self-fulfillment. In modern life, a person’s occupation often correlates with the ability to achieve these needs. Table 7.1 provides an application of Maslow’s hierarchy of needs in an occupational environment. Maslow studied self-actualized people and noted that they had strikingly similar characteristics. Some of Maslow’s key findings, in an abbreviated form, include the following: • Self-actualized people perceive reality more effectively than others and are more comfortable with it. They have an unusual ability to

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TABLE 7.1  Practical Application of

Maslow’s Hierarchy of Needs Level of Need

General Rewards

Occupational Factors

Self-actualization

Growth Achievement Advancement Creativity Self-respect Status Prestige

Challenging job Opportunities for creativity Achievement in work Promotion Social recognition Job title High status of job Feedback from the job itself Work groups or teams Supervision Professional associations Health and safety Job security Contract of employment Pay Working conditions

Self-esteem

Belonging

Safety

Physiological

Love Friendship Belongingness Security Stability Protection Food Water Sleep Sex





















detect the spurious, the fake, and the dishonest in personality. They judge experiences, people, and things correctly and efficiently. They possess an ability to be objective about their own strengths, possibilities, and limitations. This self-awareness enables them to clearly define values, goals, desires, and feelings. They are not frightened by uncertainty. Self-actualized people have an acceptance of self, others, and nature. They can accept their own human shortcomings without condemnation. They do not have an absolute lack of guilt, shame, sadness, anxiety, and defensiveness, but they do not experience these feelings to unnecessary or unrealistic degrees. When they do feel guilty or regretful, they do something about it. Generally, they do not feel bad about discrepancies between what is and what ought to be. Self-actualized people are relatively spontaneous in their behavior and even more spontaneous in their inner lives, thoughts, and impulses. They are unconventional in their impulses, thoughts, and consciousness. They are rarely nonconformists, but they seldom allow convention to keep them from doing anything they consider important or basic. Self-actualized people have a problem-solving orientation toward life instead of a self-orientation. They commonly have a mission in life, some problem outside themselves that enlists much of their energies. In general, this mission is unselfish and is involved with the philosophical and ethical. Self-actualized people have a quality of detachment and a need for privacy. Often, it is possible for them to remain above the battle, to be undisturbed by what upsets others. They are self-governing people who find meaning in being active, responsible, self-disciplined, and decisive rather than being pawns or helplessly ruled by others. Self-actualized people have a wonderful capacity to appreciate the basic pleasures of life, such as nature, children, music, and sex, again and again. They approach these basic experiences with awe, pleasure, wonder, and even ecstasy. Self-actualized people commonly have mystical or “peak” experiences, times of intense emotions in which they transcend the self. During a peak experience, they have feelings of limitless horizons and unlimited power while simultaneously feeling more helpless than ever before. There is a loss of place and time and feelings of





great ecstasy, wonder, and awe. The peak experience ends with the conviction that something extremely important and valuable has happened, and thus the person is transformed and strengthened by the experience to some extent. Self-actualized people have deep feelings of identification with, sympathy for, and affection for other people despite occasional anger, impatience, or disgust. Self-actualized people have deeper and more profound interpersonal relationships than most other adults, but not necessarily deeper than children’s. They are capable of more closeness, greater love, more perfect identification, and more erasing of ego boundaries than other people would consider possible. One consequence is that self-actualized people have especially deep ties with relatively few individuals, and their circle of friends is small. They tend to be kind or at least patient with almost everyone, yet they speak realistically and harshly of those who they feel deserve it, especially hypocritical, pretentious, pompous, or self-inflated individuals. Self-actualized people are democratic in the deepest possible sense. They are friendly toward everyone, regardless of class, education, political beliefs, race, and color. They believe it is possible to learn something from everyone. They are humble, in the sense of being aware of how little they know in comparison with what could be known and what is known by others. Self-actualized people are strongly ethical and moral. However, their notions of right and wrong and good and evil are often unconventional. For example, a self-actualized person would never consider segregation, apartheid, or racism to be morally right, although it may be legal. Self-actualized people have a keen, unhostile sense of humor. They do not laugh at jokes that hurt other people or are aimed at others’ inferiority. They can make fun of others in general or of themselves when they are foolish or try to be big when they are small. They are inclined toward thoughtful humor that elicits a smile, is intrinsic to the situation, and is spontaneous. Self-actualized people are highly imaginative and creative. The creativeness of a self-actualized individual is not of the special talent type, such as Mozart’s, but rather is like the naive and universal creativeness of unspoiled children. 

CLINICAL APPLICATION OF LEARNED OPTIMISM The new psychology that Maslow’s work referred to may turn out to be “positive clinical psychology.”24 This field of practice was born in 1998 when Martin Seligman chose it as the theme for his term as president of the American Psychological Association.25 Positive clinical psychology aims to change clinical psychology to have an equally weighted focus on both positive and negative functioning.26 The approach is based on five key bodies of empirical findings: (1) the absence of positive well-being leads to the development of disorder over time9; (2) the absence of positive characteristics predicts disorder above and beyond the presence of negative characteristics9; (3) positive characteristics interact with negative life events to predict disorder (so studying only negative life events would produce misleading results)27; (4) many aspects of well-being range from extremely negative functioning, through a neutral midpoint, to positive well-being (possibly including happiness to depression and anxiety to relaxation continuums),28 making it impossible to study exclusively negative or positive well-being; and (5) positive interventions can be as effective as other more commonly used approaches, such as cognitive therapy.29 Positive clinical psychology ultimately involves helping patients become optimistic, which, according to Martin Seligman, is our natural tendency.30 Optimism not only is a necessary step toward achieving optimal health but is also critical to happiness and a higher quality of life.

CHAPTER 7  In many instances, it is not what happens in one’s life that determines one’s direction; to a large degree, it is the response to those challenges that shapes the quality of life and determines one’s level of health. Surprisingly, it is often true that hardship, heartbreak, disappointment, and failure serve as the sparks for joy, ecstasy, compassion, and success. The determining factor is whether these challenges are viewed as stepping-stones or stumbling blocks. A person’s attitude is like his or her physical body: it must be conditioned to be strong and positive. Conditioning an attitude to be positive and optimistic requires adopting specific healthy habits. Four key areas of focus for helping patients develop a positive mental attitude are as follows: 1. Help them become aware of self-talk. Tell them that all people conduct a constant running dialogue in their heads. In time, the things people say to themselves and others percolate down into their subconscious minds. Those inner thoughts, in turn, affect the way people think and feel. Naturally, a steady stream of negative thoughts will have a negative effect on a person’s mood, immune system, and quality of life. The cure is to become aware of self-talk and then to consciously work to feed positive self-talk messages to the subconscious mind. 2. Help them ask better questions. The quality of a person’s life is equal to the quality of the questions habitually asked. For example, if a person experiences a setback, does he or she think, “Why am I so stupid? Why do bad things always happen to me?” or “Okay, what can be learned from this situation so that it never happens again? What can I do to make the situation better?” Clearly, the latter response is healthier. Regardless of the situation, asking better questions is bound to improve one’s attitude. Some examples of questions that can improve attitude and self-esteem when asked regularly include the following: “What am I most happy about in my life right now?” “What am I most excited about in my life right now?” “What am I most grateful about in my life right now?” “What am I enjoying most in my life right now?” “What am I committed to in my life right now?” “Whom do I love? Who loves me?” “What must I do today to achieve my long-term goal?” 3. Help them experience gratitude. A large body of recent work has suggested that people who are more grateful have higher levels of well-being and are happier, less depressed, less stressed, and more satisfied with their lives and social relationships.31,32 Gratitude appears to have one of the strongest links with mental health of any character trait. Helping instill a sense of gratitude has been shown to be a very successful intervention. In one study, participants were randomly assigned to one of six therapeutic interventions designed to improve the participants’ overall quality of life.33 Of these six interventions, it was found that the biggest short-term effects came from a “gratitude visit,” where participants wrote and delivered a letter of gratitude to someone in their lives. This simple gesture showed a rise in happiness scores by 10% and a significant fall in depression scores, the results of which lasted up to 1 month after the visit. The act of writing “gratitude journals,” in which participants wrote down three things they were grateful for every day, had longer-lasting effects on happiness scores. The greatest benefits

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with this practice were usually found to occur around 6 months after it began. Similar practices have shown comparable benefits. 4. Help them set positive goals. Learning to set achievable goals is a powerful method for building a positive attitude and raising self-esteem. Achieving goals creates a success cycle: a person feels better about him- or herself, and the better he or she feels, the more likely he or she is to succeed. Some guidelines for helping patients set healthy goals include the following: • Be specific. The more clearly the goal is defined, the more likely it will be achieved. For example, if a person wants to lose weight, he or she should define the desired weight and the body fat percentage or measurements to be achieved. • State the goal in positive terms and in the present tense; avoid negative words. It’s better to say, “I enjoy eating healthy, low-calorie, nutritious foods” than to say, “I will not eat sugar, candy, ice cream, and other fattening foods.” • Make the goal attainable and realistic. Start out with goals that are easily attainable, like drinking six glasses of water a day or switching from white to whole-grain bread. Initially choosing easily attainable goals creates a success cycle that helps build a positive self-image. Little things add up to make a major difference in the way a person feels about him- or herself. Counseling is necessary for the severely pessimistic individual. Forms of cognitive therapy appear to be the most useful therapy. Cognitions comprise the whole system of thoughts, beliefs, mental images, and feelings. Cognitive therapy can be as effective as the use of antidepressant drugs in the treatment of moderate depression; in addition, there tends to be a lower risk of relapse—the return of depression—with cognitive therapy.34 One reason for this is that cognitive therapy teaches people practical skills they can use to combat depression anytime, anywhere, and every day for the rest of their lives. Cognitive therapy avoids the long, drawn-out (and expensive) process of psychoanalysis. It is a practical, solution-oriented psychotherapy that teaches skills a person can apply to improve quality of life. Mental health specialists trained in cognitive therapy seek to change the way the depressed person consciously thinks about failure, defeat, loss, and helplessness. To do so, they employ five basic tactics that help patients do the following: • Recognize the automatic negative thoughts that flit through consciousness at the times when they feel the worst. • Dispute the negative thoughts by focusing on contrary evidence. • Learn a different explanation to dispute the automatic negative thoughts. • Avoid rumination (the constant churning of a thought in one’s mind) by helping the patient better control his or her thoughts. • Question depression-causing negative thoughts and beliefs and replace them with empowering, positive thoughts and beliefs.

REFERENCES See www.expertconsult.com for a complete list of references.

REFERENCES 1. Peterson C, Seligman M, Valliant G. Pessimistic explanatory style as a risk factor for physical illness: a thirty-five year longitudinal study. J Pers Soc Psychol. 1988;55:23–27. 2. Maruta T, Colligan RC, Malinchoc M, Offord KP. Optimism-pessimism assessed in the 1960s and self-reported health status 30 years later. Mayo Clin Proc. 2002;77:748–753. 3. Taylor SE, Kemeny ME, Reed GM, et al. Psychological resources, positive illusions, and health. Am Psychol. 2000;55:99–109. 4. Schweizer K, Beck-Seyffer A, Schneider R. Cognitive bias of optimism and its influence on psychological well-being. Psychol Rep. 1999;84: 627–636. 5. Chang EC, Sanna LJ. Optimism, pessimism, and positive and negative affectivity in middle-aged adults: a test of a cognitive-affective model of psychological adjustment. Psychol Aging. 2001;16:524–531. 6. Segerstrom SC. Optimism, goal conflict, and stressor-related immune change. J Behav Med. 2001;24:441–467. 7. Maruta T, Colligan RC, Malinchoc M, Offord KP. Optimists vs pessimists: survival rate among medical patients over a 30-year period. Mayo Clin Proc. 2000;75:140–143. 8. Kubzansky LD, Sparrow D, Vokonas P, Kawachi I. Is the glass half empty or half full? A prospective study of optimism and coronary heart disease in the normative aging study. Psychosom Med. 2001;63:910–916. 9. Wood AM, Joseph S. The absence of positive psychological (eudemonic) well-being as a risk factor for depression: a ten year cohort study. J Affect Disord. 2010;122:213–217. 10. Paganini-Hill A, Kawas CH, Corrada MM. Positive mental attitude associated with lower 35-year mortality: the leisure world cohort study. J Aging Research. 2018;2126368. PubMed PMID: 30595919. 11. Brennan FX, Charnetski CJ. Explanatory style and immunoglobulin A (IgA). Integr Physiol Behav Sci. 2000;35:251–255. 12. Kamen-Siegel L, Rodin J, Seligman ME, Dwyer J. Explanatory style and cell-mediated immunity in elderly men and women. Health Psychol. 1991;10:229–235. 13. Imai K, Nakachi K. Personality types, lifestyle, and sensitivity to mental stress in association with NK activity. Int J Hyg Environ Health. 2001;204:67–73. 14. Segerstrom SC. Personality and the immune system: models, methods, and mechanisms. Ann Behav Med. 2000;22:180–190. 15. Jung W, Irwin M. Reduction of natural killer cytotoxic activity in major depression: interaction between depression and cigarette smoking. Psychosom Med. 1999;61:263–270. 16. Kiecolt-Glaser JK, McGuire L, Robles TF, Glaser R. Emotions, morbidity, and mortality: new perspectives from psychoneuroimmunology. Annu Rev Psychol. 2002;53:83–107.

17. Maddock C, Pariante CM. How does stress affect you? An overview of stress, immunity, depression and disease. Epidemiol Psychiatr Soc. 2001;10:153–162. 18. Kiecolt-Glaser JK, Stephens R, Lipitz P, et al. Distress and DNA repair in human lymphocytes. J Behav Med. 1985;8:311–320. 19. Glaser R, Thorn BE, Tarr KL, et al. Effects of stress on methyltransferase synthesis: an important DNA repair enzyme. Health Psychol. 1985;4:403–412. 20. Kiecolt-Glaser JK, Glaser R. Psychoneuroimmunology and cancer: fact or fiction? Eur J Cancer. 1999;35:1603–1607. 21. Raikkonen K, Matthews KA, Flory JD, et al. Effects of optimism, pessimism, and trait anxiety on ambulatory blood pressure and mood during everyday life. J Pers Soc Psychol. 1999;76:104–113. 22. Steptoe A, Demakakos P, de Oliveira C, Wardle J. Distinctive biological correlates of positive psychological well-being in older men and women. Psychosomatic Medicine. 2012;74(5):501–508. PubMed PMID: 22511728. 23. Maslow A. The Farther Reaches of Human Nature. New York: Viking; 1971. 24. Lambert MJ, Erekson DM. Positive psychology and humanistic tradition. J Psychother Integration. 2008;18:222–232. 25. Seligman MEP, Csikszentmihalyi M. Positive psychology: an introduction. Am Psychol. 2000;55:5–14. 26. Wood AM, Tarrier N. Positive clinical psychology: a new vision and strategy for integrated research and practice. Clin Psychol Rev. 2010;30(7):819–829. 27. Johnson J, Gooding PA, Wood AM, et al. Resilience to suicidal ideation in psychosis: positive self-appraisals buffer the impact of hopelessness. Behav Res Ther. 2010;48(9):883–889. 28. Wood AM, Taylor PT, Joseph S. Does the CES-D measure a continuum from depression to happiness? Comparing substantive and artifactual models. Psychiatry Res. 2010;177:120–123. 29. Geraghty AWA, Wood AM, Hyland ME. Attrition from self-directed interventions: Investigating the relationship between psychological predictors, intervention content and dropout from a body dissatisfaction intervention. Social Sci Med. 2009;71:31–37. 30. Seligman M. Learned Optimism. New York: Knopf; 1991. 31. Wood AM, Froh JJ, Geraghty AW. Gratitude and well-being: a review and theoretical integration. Clin Psychol Rev. 2010;30(7):890–905. 32. Wood AM, Joseph S, Maltby J. Gratitude predicts psychological well-being above the Big Five facets. Pers Individ Dif. 2009;46:443–447. 33. Seligman MEP, Steen TA, Park N, Peterson C. Positive psychology progress: empirical validation of interventions. Am Psychol. 2005;60:410–421. 34. Casacalenda N, Perry JC, Looper K. Remission in major depressive disorder: a comparison of pharmacotherapy, psychotherapy, and control conditions. Am J Psychiatry. 2002;159:1354–1360.

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Primary and Adjunctive Diagnostic Procedures During the 20th century, tremendous progress was made in the development of laboratory procedures for the diagnosis of disease. However, this work focused primarily on pathological processes—typically advanced disease; little was done to help the physician recognize physiological abnormalities before they progress to the pathological stage. The problem is further aggravated for doctors of preventive/integrative/functional/natural medicine, who need to evaluate in an objective manner the nutritional status, lifestyle, physiological competency, toxic load, and vitality of their patients. The few available tests that exist tend to be oriented to measuring absolute values rather than functional indices and generally indicate abnormal values only after serious dysfunction develops. In this section, we have compiled useful assessment methodologies we believe will greatly aid healthcare professionals who want more objective tests in their evaluation of the pathophysiological status of their patients and the causes of dysfunction. These are not meant to replace the standard, pathologically oriented, diagnostic procedures. Rather, we are encouraging the use of methodologies that aid in the early diagnosis of disease susceptibility, quantification of the processes that usually precede clinical disease, and ways to objectively assess foundational causes like functional nutritional deficiencies and toxic load. Where possible, preference is given to tests that measure the uniqueness of the patient’s biochemistry rather than abstract absolute values. In keeping with the metabolic and scientific orientation of this textbook, the emphasis has been placed on those procedures that have strong support in the research literature. Most of these laboratory procedures are on the cutting edge of our understanding of the assessment of the physiological function of metabolically unique individuals. Because it is an emerging field, few experts exist, and many are employed by or associated with the commercial laboratories performing the procedures.

     

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8 Apoptosis in Health and Diseases Lise Alschuler, ND, and Aristo Vojdani*, PhD, MSc, CLS

OUTLINE Introduction, 107 Measurable Features of Apoptosis for Research Purposes, 107 Different Stages of Apoptosis, 108 Apoptosis Is Induced by Chemicals to Control Malignancy, 109 Clinical Applications, 110 Apoptosis in Cancer, 110

Apoptosis in Autoimmune Diseases, 110 Apoptosis During Viral Infection, 111 Apoptosis in Acquired Immunodeficiency Syndrome, 111 Apoptosis in the Heart and Brain, 111 Conclusions, 111

INTRODUCTION

essentially the interpretation of an apoptotic assay is fraught with unknowns—the significance of any result being dependent on a lack of a reference standard, itself determinant upon the type and number of cells assayed, the duration of apoptosis, and the timing and duration of the test.9

Apoptosis is a distinct form of cell death controlled by an internally encoded suicide program. It is believed to occur in the majority of animal cells. It is a distinct event that triggers characteristic morphological and biological changes in the cellular life cycle. It is common during embryogenesis, normal tissue and organ involution, and cytotoxic immunological reactions, and it occurs naturally at the end of the life span of differentiated cells. Apoptosis can also be induced in cells by the application of a number of different agents, including physiological activators, heat shock, bacterial toxins, oncogenes, chemotherapeutic drugs, various toxic chemicals, ultraviolet and γ-radiation, and hypoxia. When apoptosis occurs, the nucleus and cytoplasm of the cell often fragment into membrane-bound apoptotic bodies, which are then phagocytized by neighboring cells. Alternatively, during necrosis, cell death occurs by direct injury to cells, resulting in cellular lysing and the release of cytoplasmic components into the surrounding environment, often inducing an inflammatory response in the tissue. Apoptosis may occur in one cell, leaving surrounding cells unaffected, as opposed to necrosis, which affects multiple cells simultaneously. A landmark of cellular self-destruction by apoptosis is the activation of nucleases and proteases that degrade the higher-order chromatin structure of the DNA into fragments of 50 to 300 kilobases and subsequently into smaller DNA pieces of about 200 base pairs in length. Activation of proteases, notably aspartate-specific cysteinyl proteases, referred to as caspases, is of primary relevance to apoptosis. Caspase-3 is considered to be the key mediator of apoptosis of mammalian cells, with apoptotic cells characterized by significant caspase 3 activation.1 Caspase-3 expression may be measured with immunohistochemical staining with caspase 3 antibodies at 1:50 dilution (DAKO, Carpinteria, CA).2 Using fluorescent-labeled reagents, it is also possible to tag the DNA break and identify the percentage of apoptotic cells with a high degree of accuracy.3–8 Unfortunately, there is no test for apoptosis that is clinically relevant. Although there are methodological limitations,

Measurable Features of Apoptosis for Research Purposes One of the most easily measured features of apoptotic cells is the breakup of the genomic DNA by cellular nucleases. These DNA fragments can be extracted from apoptotic cells and result in the appearance of DNA laddering when the DNA is analyzed by agarose gel electrophoresis. The DNA of nonapoptotic cells, which remains largely intact, does not display this laddering on agarose gels during electrophoresis. The large number of DNA fragments appearing in apoptotic cells results in a multitude of 3′-hydroxyl termini of DNA ends. This property can also be used to identify apoptotic cells by labeling the DNA breaks with fluorescent-tagged deoxyuridine triphosphate nucleotides. The enzyme terminal deoxynucleotidyl transferase catalyzes a template-independent addition of deoxyribonucleotide triphosphates to the 3′-hydroxyl ends of double- or singlestranded DNA. A substantial number of these sites are available in apoptotic cells, providing the basis for the single-step fluorescent labeling and flow cytometric method. Nonapoptotic cells do not incorporate significant amounts of the fluorescent-tagged deoxyuridine triphosphate nucleotides due to the lack of exposed 3′-hydroxyl DNA ends. Apoptosis can also be characterized by changes in cell membrane structure. During apoptosis, the cell membrane’s phospholipid asymmetry changes—phosphatidylserine is exposed on the outer membrane, whereas membrane integrity is maintained. Annexin V specifically binds phosphatidylserine, whereas propidium iodide is a DNA-binding fluorochrome. When a cell population is exposed to both reagents, apoptotic cells stain positive for annexin V and negative for propidium iodide; necrotic cells stain positive for both, and live cells stain negative for both.5

*Previous edition contributor

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SECTION 2 

Primary and Adjunctive Diagnostic Procedures INDUCER STAGE • Toxic chemicals • Radiation • Cytokines • Withdrawal of survival factors (GH)

Chemicals Toxins Ultraviolet Cancer drugs

Live cell

Early apoptotic cell

Detection of % apoptosis by staining of membrane annexin or DNA single-strand break Late apoptotic cell Fig. 8.1 Detection of apoptosis using damaged membrane or DNA ­single-strand break and flow cytometry.

• Oxidants • Chemotherapy agents • Hormones

SENSORS/TRIGGERS or TRANSDUCING DEATH SIGNALS • Reactive oxygen • P53, C-myc

• Superoxide dismutase mutation • Fas signaling

THE EXECUTIONER • IL1-β converting enzyme • Granzymes

• Serine protease • Cysteine protease • Cyclin-dependent kinases CELL DEATH

Fig. 8.3  Various stages of “inside-out” cell death or apoptosis.

Fig. 8.2  Separation of cells by flow cytometry and detection of apoptotic population.

This process of apoptosis and its analysis by flow cytometry are shown in Figs. 8.1 and 8.2. Another assessment of apoptosis involves ex vivo cell analysis. Specifically, the expression of active caspase-3 along with the Bcl-2:Bax ratio as markers of apoptosis can be measured. Immunohistochemical staining will reveal the expression of these apoptotic-related proteins, caspase-3 and cleaved caspase-3; the latter is indicative of apoptosis.10 Bcl-2 is antiapoptotic gene product that exists in ratio to Bax and Bak, which are proapoptotic gene products. This ratio is indicative of the degree of apoptosis, with a decreased Bcl-2:Bax ratio indicative of apoptosis. Cells from Bax(−/−) and Bak(−/−) knockout animals do not respond to apoptosis inducers. In these cells, cytochrome C is not released from the mitochondrial membrane to initiate the caspase cascade.11 Thus Bax and Bak are critical to apoptosis, and their expression in relation to Bcl-2 is highly correlative to apoptosis. 

Different Stages of Apoptosis The process of apoptosis is divided into three stages: • Induction • Sensing or triggering • Execution

These stages of apoptosis are depicted in Fig. 8.3. Induction represents the initial events that signal a cell so that apoptosis may begin. This induction phase may be induced by various physical agents, such as toxic chemicals, hypoxia, radiation, chemotherapy agents, hormones, and CD95 or Fas ligation. It has been proposed that the induction stage of apoptosis is prevented by many antioxidants (vitamin C, β-carotene, and vitamin E) and also by various biological response modifiers, including lentinan, thymic hormones, viral antigens, and cytokines. It is important to note that both extrinsic and intrinsic pathways of apoptosis induction converge in the mitochondria and that the prevention or initiation of apoptosis from this point is the result of cellular redox status.12 Persistent low to moderate oxidation is consistent with the prevention of apoptosis. Low to moderate oxidative stress within the mitochondrial membrane activates Bcl-2. Bcl-2 maintains the intracellular redox status at a level that is optimal for the cell. Bcl-2 does this by increasing the mitochondrial burn rate of oxygen, thereby increasing electron leakage and oxygen concentration, relative to hydrogen peroxide, in the mitochondrial membrane. This reduces the permeability of the inner mitochondrial membrane and the opening of apoptotic pores. Further, Bcl-2 physically sequesters proapoptotic proteins, Bax and Bak.13 Bax and Bak normally facilitate the release of cytochrome C from the inner mitochondrial membrane and out into the cytosol, where it initiates the caspase cascade. However, when oxidative stress is acute or high, the inhibitory role of Bcl-2 is altered, and apoptosis can occur. Also, higher levels of reactive oxidative stress generate more hydrogen peroxide within the mitochondria, which, in turn, oxidizes other mitochondrial components, such as cardiolipin, and inner membrane phospholipid. Oxidized cardiolipin moves to the outer mitochondrial membrane and recruits Bax and Bak, thus enabling the release of cytochrome C through Bax- and Bak-controlled pores, finally activating caspases and apoptosis.14 Also in response to higher oxidative stress, p53 translocates from the cell’s nucleus to the mitochondria, where it is de-ubiquitinated and subsequently activates Bax- and Bak-induced apoptosis.15

CHAPTER 8  There is, however, a limit to the proapoptotic response to oxidative stress. When oxidative stress is overwhelmingly high and/or prolonged, oxidative damage occurs to cytochrome C and to downstream caspases preventing apoptosis. There are other apoptotic escape mechanisms present in cells as well. Mitochondrial paraoxonase enzymes PON2 and PON3 interact with ubiquinone to reduce oxygen release. This mitigates oxidation of cardiolipin, creating a resistance to apoptosis. In fact, PON2 and PON3 have been established as key factors in the prevention of atherosclerosis because endothelial and macrophage death are the basis of atherogenic plaques.16 The induction of apoptosis is entirely dependent on the redox state of the cell and the mitochondrial response to oxidation. Mitochondria can respond to moderate or acute oxidative stress by initiating apoptosis; however, excessive and/or prolonged oxidative stress prevents apoptosis. Glutathione plays a major role in controlling mitochondrial oxidative stress. Reduced glutathione (GSH) donates electrons to reactive oxygen species (ROS), thereby preventing the generation of hydrogen peroxide. In the course of donating the electron, glutathione itself becomes oxidized (GSSG). Oxidized glutathione is then regenerated back to its reduced state through the action of glutathione reductase. On the one hand, the presence of GSH facilitates the destruction of hydrogen peroxide, thereby preventing the release of cytochrome C and delaying apoptosis. This allows the cell to undergo repair, instead of apoptosis, when the oxidative stress is temporary and/or low. On the other hand, by regulating the amount of oxidation, GSH preserves mitochondrial membrane integrity and cytochrome C, ensuring that the capacity for apoptosis in the face of high and/or prolonged oxidative stress is present. If there is a deficiency of reduced glutathione or damage to glutathione reductase (for instance by arsenic trioxide or lead) in the context of high oxidative stress, the cell will be unable to initiate apoptosis.17 Instead, the cell will be forced to undergo unprogrammed cell death, or necrosis. This is an inflammatory event and will ultimately further contribute to the regional oxidative stress. Thus the induction of apoptosis is intimately connected with the cellular redox potential of cells, itself regulated primarily by glutathione. The induction stage is followed by a decision on whether or not the cell will undergo apoptosis. The decision to die is under the control of a number of different pathways or cellular sensors that induce the apoptosis signal, which then triggers the central mechanisms. During this stage, enzymes such as interleukin-1β–converting enzymes, serine protease, cysteine protease, granzymes, and cyclin-dependent kinases become activated. Once activated, these enzymes dismantle the cell and trigger the cell-surface changes that cause direct cell recognition and engulfment of the dying cells by phagocytes. These central events are prevented by various antioxidants and biological response modifiers. 

Apoptosis Is Induced by Chemicals to Control Malignancy Many chemicals have the capacity to bind to DNA, form DNA adducts, or cause DNA single-strand breaks, possibly leading to cancer. However, the body is equipped with many factors, enzymes, suppressor genes, and cellular sensors, all with the capacity to prevent the consequences of this DNA damage by activating apoptosis-inducing signals. The role of apoptosis in regulating tissue growth is readily apparent in the simple equation in which the rate of growth is equal to the difference between the rates of cell proliferation and cell death. Thus tissues expand if the rate of proliferation exceeds the rate of cell death. This is one of the reasons for suggesting that defects in apoptosis may contribute to the transformed state.

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An important prediction of the relevance of apoptosis to malignancy is that the rate of apoptosis versus mitosis should influence the behavior of a tumor. Recently, the relationship between the apoptotic and mitotic indexes in a tumor was demonstrated as predictive of outcome: a higher ratio of apoptosis to mitosis within the tumor correlated with a positive prognosis. Further, it was found that this was not simply a function of cell death per se. Tumors with a high incidence of necrosis rather than apoptosis were correlated with a poor prognosis. It therefore follows that treatments or conditions that favor apoptosis should have desirable effects and that defects in the pathways leading to apoptosis are likely to play important roles in the process of oncogenesis.6,7 Many reactive chemicals and drugs, such as acetaminophen, diquat, carbon tetrachloride, quinones, cyanide, polyhydroxy polyether, methyl mercury, and organotin, have been implicated in apoptosis (programmed cell death) and necrosis (toxic cell death).18–25 Most research on chemical induction of apoptosis is carried out with primary cultures of cell lines (e.g., neurons, thymocytes, carcinoma cells, leukemia cells, neuroblastoma, breast cancer cells, lymphoma); little has been published on the in vivo effects of chemicals on apoptotic cells in animal models and none in humans. Therefore it was of interest to examine the effects of exposure to low levels of benzene, as well as through drinking water concentrations of up to 14 ppb, on the apoptotic cell population, as well as to examine possible changes in the cell cycle progression.18 Evidence is sufficient for the carcinogenicity of benzene in humans; therefore there is no safe level of exposure to this chemical or its metabolites. Published case reports, a case series, epidemiological studies, and both cohort and case-control studies have shown statistically significant associations between leukemia and occupational exposure to benzene and benzene-containing solvents.26,27 It has been indicated that possibly 800,000 persons are exposed to benzene from coke-oven emissions at levels of less than 0.1 ppm, and 5 million may be exposed to benzene from petroleum refinery emissions at levels of 0.1 to 1 ppm. Since these studies, numerous chemicals have been implicated in apoptosis (or programmed cell death), which arises from damage to DNA. One of the authors, Vojdani, along with collaborators, hypothesized that in individuals with a certain genetic makeup, benzene or its metabolites act as haptens, which may induce programmed cell death. The study involved a group of 60 male and female subjects who were exposed to benzene-contaminated water (at concentrations up to 14 ppm for a period of 3–5 years).18 For comparison, a control group consisting of 30 healthy males and females with a similar age distribution and without a history of exposure to benzene were recruited. Using flow cytometry, the peripheral blood lymphocytes of both groups were tested for the percentage of apoptotic cell population. When exposed individuals were compared with the control group, statistically significant differences between each mean group were detected (27.5 ± 2.4 and 10 ± 2.6, respectively), indicating an increased rate of apoptosis in 86.6% of exposed individuals (P < 0.0001; Mann–Whitney U-test). Flow cytometry analysis of apoptosis in a healthy control and a patient with chronic fatigue syndrome is shown in Fig. 8.4. It has been demonstrated that benzene induction of apoptosis is caused by a discrete block of the cell-cycle progression. There is a tendency for normal cells to commit “suicide” when deprived of usual growth factors or physical contact with their neighbors due to chemical exposure, which may represent a built-in defense against metastasis. Prompt activation of apoptosis in tumor cells that leave their native tissue presumably eliminates many metastatic cells before they have a chance to proliferate. In cancer, it is tumor cells that neglect to sacrifice themselves or forget to die. Researchers increasingly describe cancer as

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0 200 400 600 800 1000 0 200 400 600 800 1000 Fig. 8.4  Enhanced apoptotic cell population in benzene-exposed individuals with chronic fatigue syndrome. Flow cytometry analysis of apoptotic cell population in negative control cells (HL-60 leukemic cell line), positive control cells (HL-60 leukemic cells treated with the Apogen camptothecin), control subjects, and benzene-exposed individuals. Peripheral blood leukocytes were isolated, cultured for 12 hours, fixed in paraformaldehyde, labeled with fluorescent-tagged deoxyuridine triphosphate nucleotides, and analyzed for apoptosis by flow cytometry.

a disease involving both excessive proliferation of cells and abandonment of their ability to die. The dysregulation of apoptosis in malignant cells underlies both the initiation and progression of cancer. Cancer develops after a cell accumulates mutations in several genes that control cell growth and survival. When a mutation seems irreparable, the affected cell usually kills itself rather than risk becoming deranged and potentially dangerous. However, if the cell does not die, it or its progeny may live long enough to accumulate mutations that enable it to divide uncontrollably and metastasize. In many tumors, genetic damage apparently fails to induce apoptosis because the constituent cells have inactivated the gene that codes for the p53 protein. This protein can lead to activation of the cell’s apoptotic machinery when DNA is injured by environmental agents, such as benzene or its metabolites. Therefore it is important to study cell suicide in health and diseases. 

CLINICAL APPLICATIONS Apoptosis in Cancer The failure of apoptosis in malignant cells in the context of irreparable DNA damage leads to tumor progression. Cancer therapies, namely chemotherapy and radiation, control cancer by inflicting cell damage, which, in turn, triggers apoptosis. Unfortunately, >50% of all human cancers involve a mutation of p53, a central gene in apoptosis. p53 stimulates both the extrinsic death receptor pathway of apoptosis as well as the intrinsic mitochondrial pathway involving a decreased Bcl2:Bax ratio. Thus it is imperative to find therapies that promote apoptosis independent of p53. Promising therapies in this regard include curcumin28 derived from Curcuma longa, genistein derived from soy,29

and resveratrol,30 all of which are under investigative study for this application. Another promising cancer treatment involves the use of recombinant human apoptosis ligands to induce tumor necrosis factor–related apoptosis-inducing ligand (TRAIL). These ligands induce apoptosis via TRAIL, a selective death receptor pathway in a broad range of cancer cell lines, while sparing most normal cell types.31 The therapeutic potential for TRAIL-inducing ligands is most promising in combination with cytotoxic chemotherapy agents. Advances in cancer therapy are likely to come in the area of targeted therapies, the majority of which trigger specific receptor-driven pathways that culminate in apoptosis. The centrality of apoptosis induction in cancer cannot be overstated. 

Apoptosis in Autoimmune Diseases In cancer, it is the tumor cells that forget to die; in autoimmunity, immune cells fail to die when they are supposed to. Virtually all tissues harbor apoptotic cells at one time or another. Damaged cells usually commit suicide for the greater good of the body; when this does not occur, disease may develop. Autoimmunity occurs when the antigen receptors on immune cells recognize specific antigens on healthy cells and cause the cells bearing those particular substances to die. Autoimmune disease results from perpetuated immune-mediated tissue destruction and can involve immune cells that are resistant to apoptosis. Under normal conditions, the body allows a certain number of self-reactive lymphocytes to circulate. These cells normally do little harm, but they can become overactive through several processes. For instance, if these reactive lymphocytes recognize some foreign antigen such as microbes on food and haptenic chemicals, then exposure to that antigen causes them to become excited. If, due to molecular

CHAPTER 8  mimicry, these antigens are similar to normal tissues, the activated cells may expand their numbers and attack the healthy tissue, thus causing an autoimmune disease.3,32,33 Autoimmune reactions usually are self-limited—they disappear when the antigens that originally set them off are cleared away. In some instances, however, the autoreactive lymphocytes survive longer than they should and continue to induce apoptosis in normal cells. Some evidence in animals and humans has indicated that extended survival of autoreactive cells is implicated in at least two chronic autoimmune syndromes—systemic lupus erythematosus and rheumatoid arthritis. In other words, the lymphocytes undergo too little apoptosis, with the result that normal cells undergo too much.34,35 

Apoptosis During Viral Infection Disturbance in the regulation of apoptosis is a component in various diseases. Viral illnesses are among the diseases caused by apoptosis dysregulation. After entering a cell, viruses attempt to shut down the cell’s ability to make any proteins except those needed to produce more virus. This act of stalling host protein synthesis is enough to induce many kinds of cells to undergo apoptosis. If the host cell dies, the virus is also eliminated. Therefore certain viruses have evolved ways to inhibit apoptosis in the cells they infect. Epstein–Barr virus, which causes mononucleosis and has been linked to lymphomas in humans, uses a mechanism that has been seen in other viruses. Epstein–Barr virus produces substances that inhibit apoptosis. Papillomavirus, a major cause of cervical cancer, inactivates p53, a central mediator of apoptosis. Cowpox virus, a relative of which is used as the smallpox vaccine, is another virus that inhibits caspase activation and attendant apoptosis. Investigators interested in antiviral therapy are now exploring ways to block the activity of the antiapoptotic molecules manufactured by viruses.34 

Apoptosis in Acquired Immunodeficiency Syndrome Induction of apoptosis by viruses in healthy cells is believed to contribute to the immune deficiency found in patients with acquired immunodeficiency syndrome (AIDS). In these patients, infection with human immunodeficiency virus (HIV) causes T-helper cells to die. As T-helper cells gradually disappear, cytotoxic cells, such as natural killer cells, also perish through apoptosis because they cannot survive without the growth signals produced by T-helper cells. When the number of T cells dwindles, so does the body’s ability to fight infections, especially viral and parasitical infections. Researchers have shown that many more helper cells succumb in addition to those that are infected with HIV. It is also highly probable that a large number of the cells die through apoptosis. Apparently, Fas plays a crucial role in this process. Normally, T cells make functional Fas only after they have been active for a few days and are ready to die. However, helper cells from AIDS patients may display high amounts of functional Fas even before the cells have encountered an antigen. This display of Fas would be expected to cause the cells to undergo apoptosis prematurely whenever they encounter Fas ligand on other cells (such as on T cells already activated against HIV or other microbes). In addition, if the primed cells encounter the antigen recognized by their receptors, they may trigger their own death. It is also possible that oxygen free radicals trigger the suicide of virus-free T cells. These highly reactive substances are produced by inflammatory cells drawn to infected lymph nodes in patients with HIV. Free radicals can damage DNA and membranes in cells. They will cause necrosis if they do extensive damage, but they can induce apoptosis if the damage is more subtle. In support of the free-radical theory, researchers have found that molecules capable of neutralizing free radicals prevent apoptosis in T cells obtained from patients with AIDS.34,35

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Therapies with antiapoptotic medication, such as Trolox, a water-soluble analog of vitamin E that prevents oxidative stress, and pyrrolidine dithiocarbamate, a potent inhibitor of nuclear factor-κB, are now the focus of AIDS and autoimmune disease studies.36,37 Additionally, protease inhibitors, which are the mainstay of HIV therapy, inhibit apoptosis in immune cells.38 The mechanism underlying the apoptosis inhibition is as of yet unknown, but interestingly, supratherapeutic doses of protease inhibitors have an opposite, proapoptotic effect. 

Apoptosis in the Heart and Brain In contrast to cancer, where cells forget to die and insufficient apoptosis occurs, excessive apoptosis accounts for much of the cell death that follows heart attacks and strokes. In the heart, vessel blockage decimates cells that were fully dependent on the vessel. Those cells die by necrosis, partly because they are catastrophically starved of the oxygen and glucose they need to maintain themselves and partly because calcium ions, which are normally pumped out of the cell, rise to toxic levels. Over the course of a few days, cells surrounding the dead zone, which initially survive because they continue to receive nourishment from other blood vessels, can die as well. Later, however, many cells die by necrosis after being overwhelmed by the destructive free radicals that are released when inflammatory cells swarm into the dead zone to remove necrotic tissue. The less injured cells commit suicide by apoptosis. If the patient is treated by restoring blood flow, still more cells may die by necrosis or apoptosis because reperfusion leads to a transient increase in the production of free radicals. Similarly, in strokes due to inflammation, the release of such neurotransmitters as glutamate leads to necrosis and apoptosis. Understanding of the factors that lead to the tissue death accompanying heart attack, stroke, and reperfusion has led to new ideas for treatment. Notably, cell death might be limited by drugs and other agents that block free-radical production or inhibit proteases. Apoptosis also accounts for much of the pathology seen in such diseases as Alzheimer’s, Parkinson’s, Huntington’s, and amyotrophic lateral sclerosis (Lou Gehrig’s disease), which are marked by the loss of brain neurons. Elevated apoptosis in these neurological diseases seems to be related to a lack of production of the nerve growth factor and to free-radical damage. It seems likely that a combination of such factors could cause many cells to destroy themselves. Manipulation of this process of cell killing may help in treating these neurological diseases. Studies in animal models imply that long-term delivery of nerve growth factors could protect against programmed cell death in these conditions. Therefore a greater understanding of the mechanisms involved in cell death should greatly enhance those important steps.32,36,39 

CONCLUSIONS Apoptosis and cell proliferation play an important role in development, differentiation, homeostasis, and aging.4–8 The balance established between these two processes depends on various growth and death signals that are influenced by diet, nutrition, lifestyle, and other environmental factors. When the equilibrium between life and death is disrupted by aberrant signals (e.g., low levels of antioxidants in the blood or tissue cells), either tissue growth or atrophy occurs. Under normal conditions with optimal nutritional factors, tissue homeostasis is sustained by balancing the effects of mitosis and apoptosis. The importance of this balance can clearly be seen when one of these processes becomes predominant (Fig. 8.5). The apoptotic potential within each cell is critical for the health of the host. Apoptosis is

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Primary and Adjunctive Diagnostic Procedures an elegant response to oxidative stress. This seemingly heroic sacrifice of self for the greater good underpins healthy living. Imbalance of apoptosis regulators, genetic mutations, and viral infections thwarts the healing effect of apoptosis. Finding ways to restore apoptotic and redox balance is critical to health.

REFERENCES See www.expertconsult.com for a complete list of references.

Fig. 8.5  The balance or imbalance between the rate of apoptosis and mitosis determines tissue homeostasis, atrophy, cell proliferation, and the development of cancer.

REFERENCES 1. Yang Min, Antoine Daniel J, Weemhoff James L, et al. Biomarkers distinguish apoptotic and necrotic cell death during hepatic ischemia-reperfusion injury in mice. Liver Transpl. 2014;20(11):1372–1382. 2. Mohamed AK, Magdy M. Caspase 3 role and immunohistochemical expression in assessment of apoptosis as a feature of H1N1 vaccinecaused drug-induced liver injury (DILI). Electron Physician. 2017;9(5):4261–4273. 3. Wyllie AH, Kerr JF, Currie AR. Cell death: the significance of apoptosis. Int Rev Cytol. 1980;68:251–306. 4. White E. Life, death and the pursuit of apoptosis. Genes Dev. 1996;10:1–15. 5. Jarvis WD, Kolesnick RN, Fornari FA, et al. Induction of apoptotic DNA damage and cell death by activation of the sphingomyelin pathway. Proc Natl Acad Sci U S A. 1994;91:73–77. 6. Green DR, Martin SJ. The killer and the executioner: how apoptosis controls malignancy. Curr Opin Immunol. 1995;7:694–703. 7. Arends MJ, McGregor AH, Wyllie AH. Apoptosis is inversely related to necrosis and determines net growth in tumors bearing constitutively expressed myc, ras and HPV oncogenes. J Pathol. 1994;144:1045–1057. 8. Marchetti P, Hirsch T, Zamzami M, et al. Mitochondrial permeability triggers lymphocyte apoptosis. J Immunol. 1996;157:4830–4836. 9. Renehan AG, Booth C, Potten CS. What is apoptosis, and why is it important? BMJ. 2001;322(7301):1536–1538. 10. Amatya JL, Takeshima Y, Shrestha L, et al. Evaluation of apoptosis and immunohistochemical expression of the apoptosis-related proteins in mesothelioma. Hiroshima J Med Sci. 2010;59(2):27–33. 11. Kandasamy K, Srinivasula SM, Alnemri ES, et al. Involvement of proapoptotic molecules Bax and Bak in tumor necrosis factor-related apoptosisinducing ligand (TRAIL)-induced mitochondrial disruption and apoptosis: differential regulation of cytochrome C and Smac/DIABLO release. Cancer Res. 2003;63(7):1712–1721. 12. Watson WH, Cai J, Jones DP. Diet and apoptosis. Annu Rev Nutr. 2000;20:485–505. 13. Krishna S, Low I, Pervaiz S. Regulation of mitochondrial metabolism: yet another facet in the biology of the oncoprotein Bcl-2. Biochem J. 2011;435:545–551. 14. Li XX, Tsoi B, Kurihara H, He RR. Cardiolipin and its different properties in mitophagy and apoptosis. J Histochem Cytochem. 2015;63(5):301–311. 15. Szczepanek K, Lesnefsky EJ, Larner AC. Multi-tasking: nuclear transcription factors with novel roles in the mitochondria. Trends Cell Biol. 2012;22(8):429–437. 16. Witte I, Foerstermann U, Devarajan A, Reddy ST, Horke S. Protectors or traitors: the roles of PON2 and PON3 in atherosclerosis and cancer. J Lipids. 2012;2012:342806. 17. Ray A, Chatterjee S, Mukherjee S, Bhattacharya S. Arsenic trioxide induced indirect and direct inhibition of glutathione reductase leads to apoptosis in rat hepatocytes. Biometals. 2014;27(3):483–494. 18. Vojdani A, Mordechai E, Brautbar N. Abnormal apoptosis and cell cycle progression in humans exposed to methyl tertiary-butyl ether and benzene contaminating water. Human Exp Toxicol. 1997;16:485–494. 19. Walker PR, Smith C, Youdale T, et al. Topoisomerase II-reactive chemotherapeutic drugs induce apoptosis in thymocytes. Cancer Res. 1991;51:1078–1085.

20. Brown DB, Sun XM, Cohen GM. Dexamethasone-induced apoptosis involves cleavage of DNA to large fragments prior to internucleosomal fragmentation. J Biol Chem. 1993;268:3037–3039. 21. Reynolds ES, Kanz MF, Chicco P, Moslen MT. 1.1-Dichloroethylene: an apoptotic hepatotoxin? Environ Health Perspect. 1984;57:313–320. 22. Aw TY, Nicotera P, Manzo L, Orrenius S. Tributyltin stimulates apoptosis in rat thymocytes. Arch Biochem Biophys. 1990;283:46–50. 23. Rossi AD, Larsson O, Manzo L, et al. Modification of Ca2+ signaling by inorganic mercury in PC12 cells. FASEB. 1993;7:1507–1514. 24. Kunimoto M. Methyl mercury induces apoptosis of rat cerebellar neurons in primary culture. Biochem Biophys Res Commun. 1994;204:310–317. 25. Vivian B, Rossi AD, Chow SC, Nicotera P. Organotin compounds induce calcium overload and apoptosis in PC12 cells. Neurotoxicology. 1995;16:19– 25. 26. Ledda-Columbano GM, Coni P, Curto M, et al. Induction of two different modes of cell death, apoptosis and necrosis in rat liver after a single dose of thioacetamide. Am J Pathol. 1991;139:1099–1109. 27. Agency for Toxic Substances and Disease Registry (ATSDR). Toxicological Profile for Benzene, Draft Report. Atlanta, GA: Department of Health and Human Services. 28. Saha A, Kuzuhara T, Echigo N, Fujii A, et al. Apoptosis of human lung cancer cells by curcumin mediated through up-regulation of “growth arrest and DNA damage inducible genes 45 and 153.” Biol Pharm Bull. 2010;33(8):1291–1299. 29. Li Y, Upadhyay S, Bhuiyan M, Sarkar FH. Induction of apoptosis in breast cancer cells MDA-MB-231 by genistein. Oncogene. 1999;18:3166–3172. 30. Fulda S, Debatin KM. Sensitization for tumor necrosis factor-related apoptosis-inducing ligand-induced apoptosis by the chemopreventive agent resveratrol. Cancer Res. 2004;64(1):337–346. 31. Ashkenazi A, Holland P, Eckhardt SG. Ligand-based targeting of apoptosis in cancer: the potential of recombinant human apoptosis ligand 2/tumor necrosis factor-related apoptosis-inducing ligand (rhApo2L/TRAIL). J Clin Oncol. 2008;26(21):3621–3630. 32. National Institute of Environmental Health Sciences. Sixth Annual Report on Carcinogens. Benzene Case No. 71-43-2:35. Research Triangle Park, NC: National Institute of Environmental Health Sciences 33. Golstein P, Ojcius DM, Ding-E Young J. Cell death mechanisms and the immune system. Immunol Rev. 1991;121:29–65. 34. Cohen JJ, Duke RC, Fadok VA, Sellins KS. Apoptosis and programmed cell death in immunity. Ann Rev Immunol. 1992;10:267–293. 35. Duke RC, Ojcius DM, Ding-E Young J. Cell suicide in health and disease. Sci Am. 1996;275:80–87. 36. Martin SJ, Green DR. Protease activation during apoptosis: death by a thousand cuts. Cell. 1995;82:349–352. 37. Forrest VJ, Kang Y, McClain DE, et al. Oxidative stress-induced apoptosis prevented by Trolox. Free Radic Biol Med. 1994;16:675–684. 38. Rizza SA, Badley AD. HIV protease inhibitors impact on apoptosis. Med Chem. 2008;4(1):75–79. 39. Schreck R, Meier B, Mannel DN, et al. Dithiocarbamates as potent inhibitors of nuclear factor kB activation in intact cells. J Exp Med. 1992;175:1181–1194.

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9 Bacterial Overgrowth of the Small Intestine Breath Test Mary James, ND

OUTLINE Introduction, 113 Conditions Associated With Small Intestinal Bacterial Overgrowth, 113 Pathophysiology, 113 Signs and Symptoms, 114 Diagnosis, 115 Endoscopy, 115 Breath Testing, 115

INTRODUCTION Small intestinal bacterial overgrowth (SIBO) is an abnormal colonization within the small bowel by bacteria normally found in the colon, mouth, or pharynx.1 SIBO is a major contributor to irritable bowel syndrome (IBS) and uncomfortable symptoms such as bloating, abdominal discomfort, and changes in the stool (e.g., diarrhea).2 It is also a potentially serious disorder that can lead to problems such as malabsorption and weight loss, anemia, malnutrition,2 increased intestinal permeability,3 and bone loss.4 Breath testing for hydrogen (H2) and methane (CH4) provides a simple, noninvasive means of detecting SIBO. Once SIBO has been identified, antimicrobials are typically administered to eradicate the bacteria. Concurrent attention to underlying causes is also essential in preventing recurrences.

Conditions Associated With Small Intestinal Bacterial Overgrowth SIBO, whose overall prevalence is not yet clear, is an overlooked contributing factor in several common disorders.5 Several studies, for example, have demonstrated the presence of SIBO in patients with IBS.6,7 In one study, in which 84% of patients with IBS tested positive for SIBO (vs. 20% of healthy controls), successful eradication of SIBO led to a 75% improvement (compared with a 36.7% improvement in those with incomplete eradication and an 11% improvement in participants receiving a placebo).8 SIBO has also been observed in patients with acne rosacea,9 Crohn’s disease,10 restless legs syndrome,11 nonalcoholic fatty liver disease,12 interstitial cystitis,13 chronic prostatitis,14 chronic fatigue syndrome,15 and fibromyalgia.16 SIBO may increase intestinal permeability (a.k.a. “leaky gut”),17 an abnormality that was shown in a small study to resolve in 75% of patients successfully treated for SIBO.3 Investigators who found leaky gut in 37.5% of patients with fibromyalgia suggested exposure of immune cells to luminal antigens and consequent immune modulation as a likely mechanism for the pain syndrome.18

Treatment of Sibo, 116 Bacterial Eradication, 116 Antibiotics, 116 Herbal Antibiotics, 116 Antibiotic Alternatives, 117 Addressing the Underlying Causes, 117 Dietary Support, 117

A variety of anatomical and motor disorders of the small bowel can lead to SIBO, including surgical blind loops, diverticula, strictures, adhesions, tumors, fistulas,19 sclerodermas,20 intestinal pseudoobstruction,21 and diabetic enteropathy.22 Jejunal diverticulosis5 and Crohn’s disease23 have both been associated with SIBO, particularly in patients with previous intestinal surgery. Because the symptoms of Crohn’s disease and SIBO can be similar, symptoms from SIBO can be mistaken for a Crohn’s-related acute flare.10 Although the concentration of bacteria normally increases exponentially toward the distal end of the small intestine,19 far fewer bacteria inhabit the small intestine than do the colon.24 A common feature of most of these disorders is stasis of small bowel contents, which allows bacterial concentrations to increasingly resemble those of the large intestine (Box 9.1).24,25 Although many of the bacteria found in SIBO are beneficial within the colon, these same microorganisms can have deleterious effects within the delicate environment of the small intestine. Interestingly, many patients with celiac disease whose symptoms persist despite a gluten-free diet have been shown to have SIBO, with improvement only after bacterial eradication.26 The incidence of SIBO also increases with age.27 It has been found that 64% of individuals more than 75 years of age with chronic diarrhea have colonic-type flora in their small bowels,5 and that SIBO is the most common cause of clinically significant malabsorption in elderly persons.19 

Pathophysiology Two major factors that control the numbers and types of bacteria within the small bowel are intestinal motility and gastric acid secretion.19,24 Accordingly, SIBO has been associated with both intestinal stasis and hypochlorhydria.25 Other factors influencing SIBO include pancreatic enzyme secretion,28 disaccharidase production by microvilli,29 ileocecal valve function,30,84 bile salts, luminal pH, oxidation-reduction potential,24 and migrating motor complex function.31 The migrating motor complex (MMC) is a system of electrical waves that “migrate” throughout the small intestine, serving to propel

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BOX 9.1  Causes of Small Intestinal Bacterial

BOX 9.2  When to Consider Breath Testing

• Achlorhydria, hypochlorhydria, drug-induced hypoacidity • Chronic constipation • Stasis resulting from structural changes (e.g., diverticulosis, blind loops, radiation damage, stricture, fistulas, intestinal pseudo-obstruction, adhesions resulting from prior surgery) • Dysfunctional migrating motor complex • Chronic pancreatic insufficiency • Disaccharidase deficiencies (e.g., lactase) • Dysfunctional ileocecal valve • Immunodeficiency (especially of secretory immunoglobulin A) • Diabetes mellitus • Scleroderma • Crohn’s disease

• Gas, bloating, or diarrhea, usually after eating • Irritable bowel syndrome, either diarrhea or constipation-dependent • Unexplained weight loss • Evidence of malabsorption • Chronic hypochlorhydria or achlorhydria • Use of acid-blocking medications (especially proton-pump inhibitors) • Prior intestinal surgery, chronic constipation, or other causes of intestinal stasis • Intolerance of disaccharides (e.g., lactose) • Unexplained vitamin B12 deficiency, weight loss, or bone loss • Unexplained nutrient insufficiencies (e.g., calcium, magnesium, fat-soluble vitamins) • Unexplained “leaky gut” • Crohn’s disease (especially if history of strictures or small bowel resection) • Restless legs syndrome • Nonalcoholic fatty liver disease • Interstitial cystitis

Overgrowth

luminal contents all the way from the stomach to the terminal ileum over a period of 113 to 230 minutes, depending on the individual.32 The MMC has been referred to as the “intestinal housekeeper.” Its influence on motility is independent of the peristalsis that occurs in the large intestine. For instance, whereas colonic peristalsis is stimulated by eating a meal, the MMC is only active in the fasting state. The MMC consists of four phases. Phase I, which takes place in the stomach, is devoid of contractions. Phase II is composed of lowamplitude, irregular contractions that progress from the stomach to the small intestine. Phase III, initiating in either the stomach or the small intestine, is the most active phase of the MMC; contractions are of high amplitude and travel the length of the small bowel, serving to cleanse it of food from a recent meal. Phase IV represents a brief transition period back to phase I.31,32 MMC dysfunction has been demonstrated in many individuals with SIBO, especially in Phase III.33 For SIBO to produce clinical consequences, an adequate concentration of organisms with particular metabolic properties within specific locations of the small intestine is required. For example, a heavy concentration of strict anaerobes and coliforms in the proximal small intestine is more likely to be associated with malabsorption than a flora consisting of fewer strict anaerobes or coliforms or when strict anaerobes or coliforms are confined to the distal small intestine.24 For this reason, SIBO may be asymptomatic in some individuals yet produce signs and symptoms in others. Box 9.2 outlines clinical signs and symptoms that should alert the practitioner to consider testing for SIBO. 

for Small Intestinal Bacterial Overgrowth

BOX 9.3  Signs and Symptoms of Bacterial

Overgrowth

• Gas, bloating, and flatulence • Diarrhea or constipation • Abdominal cramping • Steatorrhea • Lactose intolerance • Megaloblastic anemia

Signs and Symptoms The classic SIBO syndrome is characterized by megaloblastic anemia resulting from vitamin B12 deficiency and weight loss and diarrhea secondary to fat malabsorption.24 However, many patients present with nonspecific symptoms 1 to 2 hours after a meal, including bloating, flatulence, and abdominal pain resulting from bacterial fermentation of intraluminal sugars and associated gas production, and constipationpredominant SIBO is also possible (Box 9.3).15,26 Via secretory and osmotic processes, diarrhea may occur even in the absence of significant steatorrhea. Unabsorbed fats and bile salts are modified by bacteria in the colon to hydroxylated fats and free bile acids, respectively, which stimulate colonic secretion of water and electrolytes.24 Bile salts, essential to fat emulsification and assimilation, must be conjugated with taurine or glycine to function properly. In SIBO, bacteria in the proximal small intestine can deconjugate bile salts to form free bile acids.24 This can have two major clinical repercussions:

Fig. 9.1 In small intestinal bacterial overgrowth, free bile acids can damage the brush border, resulting in reduced enzyme activity and maldigestion. (Courtesy of Genova Diagnostics, Asheville, NC.)

(1) free bile acids can promote mucosal damage (Fig. 9.1), resulting in reduced brush-border enzyme activities (especially lactase),34 defects in mucosal uptake of sugars and amino acids, enteric blood loss, and protein-losing enteropathy; or (2) the conjugated bile salt

CHAPTER 9 

Bacterial Overgrowth of the Small Intestine Breath Test

concentration may fall below the concentration necessary for effective micelle formation, resulting in fat malabsorption, steatorrhea,24,25 and deficiencies of fat-soluble vitamins.2 Fat malabsorption in SIBO can also result from mechanical interference, specifically the formation of a pseudomembrane, thought to represent a maladaptive defense mechanism against the bacterial overgrowth.35 Unabsorbed fatty acids can form insoluble soaps with calcium and magnesium, rendering them unavailable.2 Osteomalacia, night blindness, hypocalcemic tetany,19 or metabolic bone disease4 may develop as a consequence of lipid malabsorption in patients with SIBO. Although rare, iron-deficiency anemia may result from blood loss2 or possibly from an inflammation-induced upregulation of hepcidin, the body’s main iron-regulating hormone.36 SIBO may also lead to vitamin B12 deficiency, with megaloblastic anemia and low serum cobalamin levels.19,24 Although intrinsic factor is not altered by anaerobic bacteria, microbes are capable of detaching vitamin B12 from the intrinsic factor, as well as directly using B12.30 Either mechanism can make the vitamin unavailable. Paradoxically, serum folate values are usually normal or even elevated in SIBO, a result of the bacterial synthesis of the vitamin.37 Hypoproteinemia may also occur in SIBO, secondary to proteinlosing enteropathy and protein malabsorption.2,25 In addition, bacteria may metabolize proteins to ammonia and fatty acids, thereby rendering them unavailable to the host.34  The composition of bacterial populations contaminating the small bowel is complex and variable.19 However, the diagnosis of SIBO tends to be oriented less to the identification of specific microorganisms and more to overall bacterial concentrations.19

DIAGNOSIS Endoscopy Culture of a small bowel aspirate (typically jejunal or duodenal) via endoscopy is a direct method for diagnosing SIBO; abnormally high bacterial counts confirm the diagnosis.25 Although this technique has been considered the gold standard for diagnosing SIBO, intubation methods are invasive, time-consuming, uncomfortable, and expensive. It also has several shortcomings: (1) because the aspirate is typically taken from only one location, SIBO in the more distal end of the small bowel or concentrated in a large diverticulum or blind loop may be missed38; (2) false positives can result from bacterial contamination from the mouth or esophagus39; and (3) the traditional threshold of >105 cfu/mL is not well validated and may only be appropriate for patients with blind loop syndrome as a result of past surgeries (e.g., Billroth II procedure). It is now generally agreed that a lower cutoff of 103 cfu/mL is sufficient for a diagnosis of SIBO.40,41 

Breath Testing Breath tests were devised as less invasive alternatives to intubation and culture, offering greater patient comfort and convenience. They also offer good sensitivity42: a meta-analysis of 12 studies found that lactulose and glucose hydrogen breath testing identified SIBO in 54% and 31% of patients with IBS, respectively, compared with only 4% of the patients via jejunal aspirate and culture.43 Breath tests are based on the ability of intestinal microbes to ferment carbohydrates, producing H2 or CH4 in the process. A fraction of these gases naturally diffuses from the bowel to the circulation and is excreted with expired air. Because there is no other metabolic source of H2 and CH4, pulmonary excretion of these gases is used as a measure of bacterial fermentation during the passage through the bowel.44

115

Breath tests for SIBO commonly employ either lactulose or glucose, a prescribed dose of which is ingested following 1 to 2 days of dietary fiber restriction and a 12-hour fast.45 In all cases, intestinal bacteria modify the challenge substance, producing an early peak in breath gas values in patients with SIBO. Lactulose is a synthetic, nonabsorbed disaccharide that offers the advantage of traveling the full length of the small intestine. An early H2 (and/ or CH4) peak is typically followed by a prolonged gas peak representing colonic bacterial activity (approximately 90 minutes into the collection process).42,46 Glucose, an absorbable monosaccharide, is not suitable for patients with blood sugar disorders such as diabetes, and its rapid absorption reduces the test’s sensitivity in the distal ileum.42 However, its superior diagnostic accuracy in some studies has led to a growing consensus in favor of glucose over lactulose.47 Differences in methodology between studies may have contributed to the wide range of sensitivities and specificities for lactulose versus glucose (e.g., 31% to 68% and 44% to 100%, respectively, for lactulose; vs. 20% to 93% and 30% to 86%, respectively, for glucose).41 During a breath test, breath specimens are collected by exhaling into a special mouthpiece connected to a vacuum-sealed collection tube. A fasting (prechallenge) breath specimen is collected, a specified amount of lactulose or glucose is ingested, and then nine more breath specimens are typically collected at timed intervals every 15 to 20 minutes. Breath levels of H2 and CH4 are plotted over time, with earlier rises in breath gas values corresponding to more proximal portions of the small intestine. CO2 is also measured because insufficient amounts of CO2 will invalidate results for H2 and CH4.

Hydrogen Versus Methane Versus Hydrogen Sulfide Many studies using carbohydrate challenges have measured only breath H2. However, 30% to 50% of H2 producers also produce CH4,48 most likely a result of “methanogenic” bacteria, which consume H2, producing CH4 in the process.45 Individuals whose intestines harbor methanogenic bacteria typically produce greater amounts of breath CH4 during the test, thus being potentially missed on a test measuring only H2.49 Because of the lack of consistency and standardization across studies, clinics, and practitioners, a North American group of clinician scientists met for discussion in May 2015.40 Consensus was reached that CH4 should be measured along with H2, especially in cases of constipation or slow transit time. Some individuals with SIBO also appear to produce hydrogen sulfide (H2S), a result of intestinal sulfate-reducing bacteria utilizing H2 equivalents such as acetate and formate. H2S is not apparent on the standard breath test measuring H2 and CH4, and in such a case, the breath gases values may form a flat line. Currently available gas chromatography equipment cannot detect H2S. However, a preliminary study examining breath H2S offers promise in diagnosing H2-negative individuals with SIBO.50 Clinical correlations have been noted between various disorders and the production of H2 versus CH4. In one study, individuals producing higher amounts of H2 relative to CH4 reported significantly increased bloating and cramping after carbohydrate ingestion, whereas individuals producing high CH4 reported no significant increase in these symptoms.51 Specific IBS symptoms also vary with breath gas values. For example, CH4 production has been associated more with constipation-predominant IBS, whereas H2 production tends to be more associated with diarrhea.52 SIBO, in general, appears to be more common in diarrhea-predominant IBS than in constipation-predominant IBS.43 

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SECTION 2 

Primary and Adjunctive Diagnostic Procedures

Interpretation of Breath Testing Lactulose is normally not fermented until it reaches the bacteria-rich colon. As a result, the typical fasting breath sample contains less than 20 ppm of H2 or CH4. An increase in breath gas levels in the later breath specimens (90 and 120 minutes) usually reflects colonic bacterial fermentation and is considered normal. Lack of the expected colonic peak can result from antibiotics or an acidic colonic pH.53,54 In patients with SIBO, the lactulose is typically fermented in the small intestine, resulting in an early peak in breath gas values.42 According to the consensus meeting for SIBO in May 2015, a positive test result (indicating SIBO) is defined by a rise in H2 of ≥20 ppm above baseline (or a rise in CH4 of ≥10 ppm above baseline), occurring less than 90 minutes after lactulose or glucose ingestion.40 A double-peak is not considered necessary for diagnosis. Elevated baseline values occur in up to one-third of patients with SIBO53 and have been proposed to relate to the fermentation of endogenous brush-border glycoproteins,55 although future studies are needed to confirm the clinical significance of this finding.40 Various factors may interfere with the breath test, resulting in false-negative or false-positive results. Detailed instructions for breath collection help minimize this interference. False-positive results.  The following factors may account for a false-positive result on a breath test: • Failure to fast for at least 12 hours before the test or to avoid dietary fiber the day before collection can result in excessive “background noise” that contributes to the overall concentration of breath gases.29 • Sleeping, smoking, or eating shortly before or during sample collection can increase concentrations of breath gases.56 • Fermentation by oropharyngeal flora can lead to early, transient elevations in breath gases after carbohydrate ingestion.57 As a result, it is recommended that teeth and tongue brushing be performed before specimen collection.  False-negative results.  False-positive results on a breath test can be caused by the following factors: • Diarrhea or the recent administration of antimicrobials can temporarily reduce the concentration of gut bacteria,58 thus obscuring SIBO. Laxatives and enemas pose a similar risk.59 Patients are advised to wait at least 1 week after antibiotic therapy before performing the test. • SIBO confined to the distal ileum may go undetected if the breath gas peak produced in the ileum merges with the breath gases produced by the colonic flora.42 • Rapid intestinal transit may cause delayed increases in breath gases, leading to a rise only after the lactulose has already reached the cecum.60 This is particularly relevant for patients with SIBO who have undergone small bowel resection. 

TREATMENT OF SIBO For a successful clinical outcome, the treatment of SIBO should not only eradicate the bacterial overgrowth but also address symptoms, underlying causes, and complications of SIBO, such as nutrient deficiencies. Although relapses are common, identifying and treating the individual root causes of SIBO can greatly minimize this potential.

Bacterial Eradication Most patients with clinically significant SIBO host an intestinal flora consisting largely of anaerobes; however, some patients harbor a predominance of gram-negative aerobes, such as Escherichia coli, Klebsiella, and Pseudomonas.61 As a result, the most effective antimicrobial agents are those that target both aerobic and anaerobic microorganisms.19 

Antibiotics According to a meta-analysis of 10 studies using different antibiotics to treat SIBO, antibiotics were superior to placebo in normalizing H2 breath tests (51% efficacy for antibiotics compared with 9.8% for placebo).62 Historically, the first-line antibiotic for SIBO has been tetracycline (250 mg four times daily for 7 days).19 However, the high prevalence of bacterial resistance to this drug (up to 60% of patients with SIBO)19 has led to the use of alternative antibiotics. Common alternatives include metronidazole, clindamycin, neomycin, and rifaximin; amoxicillin, ampicillin, chloramphenicol, erythromycin, ciprofloxacin, and trimethoprim/sulfamethoxazole have been used less frequently.41 The duration of treatment has varied in studies as much as the choice of antibiotic, ranging from 5 days to 1 month. The minimally absorbed and broad-spectrum antibiotic rifaximin is increasingly recognized for its effectiveness and minimum of side effects.63 Rifaximin has been widely studied for its use in functional bowel disorders, including SIBO, and was approved by the U.S. Food and Drug Administration (FDA) in 2015 for diarrhea-predominant IBS. In one study, a 7-day course of rifaximin at 400 mg three times daily normalized breath H2 excretion in 70% of patients with SIBO, whereas tetracycline normalized H2 excretion in only 27% of patients.64 In a larger 7-day study, rifaximin at 400 mg three times daily normalized H2 excretion in 63.4% of patients with SIBO, compared with 43.7% of patients with SIBO taking metronidazole.65 Longer treatment durations of 10 to 14 days are common.63 In cases of excess CH4 production, the addition of neomycin (e.g., 500 mg twice daily) to rifaximin, ideally for 14 days, has been found to be more effective than rifaximin alone.66,67 This is because Methanobrevibacter smithii, the bacterium considered most responsible for CH4 production in the gut, is commonly resistant to many antibiotics. A poor response to antibiotics may indicate mucosal disease, antibiotic resistance, antibiotic-associated diarrhea, or an incorrect diagnosis.30,68 Recurrence of symptoms after treatment suggests the need for follow-up testing and possible retreatment, as well as a closer examination of underlying causes. Older age, history of surgery such as appendectomy, and chronic use of proton-pump inhibitors increase the likelihood of recurrence.69 Because prolonged antibiotic therapy significantly raises the risk of diarrhea, Clostridium difficile infection, and bacterial resistance,19 the administration of probiotics is often advised to minimize such side effects.29 Certain probiotics may also reduce breath H2 in some patients with SIBO.70 However, this is an area of ongoing research in SIBO because probiotics have also been observed to exacerbate symptoms in patients.71 

Herbal Antibiotics Because conventional antibiotics have shown variable success in eradicating SIBO and can come with side effects (most) or a high price tag (rifaximin), interest has been steadily growing in the use of various botanical agents with antimicrobial activity. Small intestinal fungal overgrowth (SIFO) is also present in some patients with SIBO; thus herbal agents may offer the additional advantage of antifungal activity. Anecdotally, some of the more common antimicrobial and/or antifungal herbs used for SIBO include berberine sulfate or berberinecontaining herbs, for example, goldenseal (Hydrastis canadensis), barberry (Berberis vulgaris), or goldthread (Coptis chinensis); oregano (Origanum vulgare); allicin (stabilized garlic extract); and neem (Azadirachta indica). In the first formal study examining the efficacy of herbal agents in patients with confirmed SIBO, over a 4-week period, 67 patients received rifaximin and 37 patients received various herbal

CHAPTER 9 

Bacterial Overgrowth of the Small Intestine Breath Test

combinations (totaling 27 herbs) known to have antibacterial and/or antifungal properties.72 At follow-up, 46% of the patients in the herbal therapy group had negative lactulose breath tests, compared with 34% of the patients in the rifaximin group. 

Antibiotic Alternatives Peppermint oil, which has been used successfully in patients with IBS, is a volatile oil with antimicrobial properties.73 Although entericcoated peppermint oil (dose of 0.2 mL three times a day) dramatically reduced gastrointestinal symptoms and reduced breath H2 in a patient with SIBO,74 further research is needed before drawing conclusions about its effectiveness in SIBO. 

Addressing the Underlying Causes Bacterial overgrowth of the small intestine may easily recur if the root causes are not addressed. 

Restoration of Gastric Acidity Because gastric acidity is a critical deterrent to SIBO, restoration of normal stomach pH in patients with hypochlorhydria or achlorhydria is essential. This may include the use of betaine hydrochloride with meals or the discontinuation of antacid medications. A 2017 meta-analysis of 19 studies concluded that the use of proton-pump inhibitors moderately increases the risk of SIBO.75 

Normalization of Intestinal Motility As mentioned, intestinal stasis is a major contributing factor to SIBO. When not a result of anatomical or organic causes, reduced motility may be improved with measures such as increased dietary fiber (especially partially hydrolyzed guar gum, which may be safer in SIBO than other forms of fiber76 and even enhance the effect of rifaximin77), water, probiotics, stress management, and exercise. As stated, impairments in the migrating motor complex (MMC) have been noted in patients with SIBO. The MMC is influenced by both gastrointestinal hormones and the central nervous system. The most active phase of the MMC, Phase III, is induced by serotonin, motilin, and ghrelin. Accordingly, low doses of promotility agents such as serotonin agonists (e.g., tegaserod, prucalopride, or cisapride) and motilin receptor agonists (e.g., azithromycin or erythromycin) are increasingly included in a comprehensive approach to SIBO patients, aimed at preventing relapse71; low-dose naltrexone, an opioid antagonist that interacts with the immune system, is also sometimes employed.78 This is an area of continuing research. In one such study of patients successfully treated for SIBO, tegaserod was shown to dramatically extend

117

symptom-free days posttreatment, and both tegaserod and erythromycin were superior to no prevention at all.79 Abdominal/pelvic adhesions (e.g., from prior surgeries) can sometimes restrict motility in the gastrointestinal tract. Anecdotally, such adhesions may be amenable to visceral manipulation. 

Dietary Support An elemental formula supplies daily nutrition in an easy-to-assimilate form and does not contain carbohydrate residues that can feed bacteria. In a study of 124 patients with IBS with SIBO, an elemental diet was found to normalize lactulose breath tests in 80% of patients after 14 days, a statistic not observed with antibiotics; another five patients achieved a negative breath test after following the diet for an additional 6 days, raising the overall success rate to 85%.80 The precise mechanisms behind the success of an elemental diet are still unclear, although they are postulated to include nutrient deprivation of enteric microbes, stimulation of Phase III of the MMC, and/or stimulation of intestinal immunity.80 Diet is increasingly recognized as a critical factor determining success in the treatment of SIBO. Because bacteria thrive on enteric carbohydrates, restricting dietary fermentable oligosaccharides, disaccharides, monosaccharides, and polyols (FODMAPs) can theoretically help reduce symptoms and reduce bacterial counts. A systematic review found that a low-FODMAP diet ameliorated IBS symptoms in all FODMAP studies examined.81 Adequate spacing of meals (e.g., at least 4–5 hours apart) is another important therapeutic consideration, based on the fact that the MMC is only active in the fasting state. Patients with SIBO may become lactose intolerant as a result of disaccharidase deficiency. This is often ameliorated with bacterial eradication82; however, temporary avoidance of all disaccharides—the premise of the “specific carbohydrate diet”—can also help “starve” the excess bacteria and allow healing of the intestinal lining.83 Substituting more easily absorbed medium-chain triglycerides for most dietary fat may be helpful in patients with diarrhea and steatorrhea.19 Further research is needed into the role of diet in the treatment and especially the maintenance of remission in SIBO. In the meantime, practitioners continue to experiment and refine various approaches.

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References

51. Kajs TM, Fitzgerald JA, Buckner RY, et al. Influence of a methanogenic flora on the breath H2 and symptom response to ingestion of sorbitol or oat fiber. Am J Gastroenterol. 1997;92:89–94. 52. Pimentel M, Mayer AG, Park S, et al. Methane production during lactulose breath test is associated with gastrointestinal disease presentation. Dig Dis Sci. 2003;48:86–92. 53. Romagnuolo J, Schiller D, Bailey RJ. Using breath tests wisely in a gastroenterology practice: an evidence-based review of indications and pitfalls in interpretation. Am J Gastroenterol. 2002;97:1113–1126. 54. Vogelsang H, Ferenci P, Frotz S, et al. Acidic colonic microclimate—possible reason for false negative hydrogen breath tests. Gut. 1988;29:21–26. 55. Perman JA, Modler S. Glycoproteins as substrates for production of hydrogen and methane by colonic bacterial flora. Gastroenterol. 1982;83: 388–393. 56. Solomons N. Evaluation of carbohydrate absorption: the hydrogen breath test in clinical practice. Clin Nutr J. 1984;3:71–78. 57. Thompson DG, O’Brien JD, Hardie JM. Influence of the oropharyngeal microflora on the measurement of exhaled breath hydrogen. Gastroenterol. 1986;91:853–860. 58. Gilat T, Ben Hur H, Gelman-Malachi E, et al. Alterations of the colonic flora and their effect on the hydrogen breath test. Gut. 1978;19:602–605. 59. Solomons NW, Garcia R, Schneider R, et al. H2 breath tests during diarrhea. Acta Paediatr Scand. 1979;68:171–172. 60. Caride VJ, Prokop EK, Troncale FJ, et al. Scintigraphic determination of small intestinal transit time: comparison with the hydrogen breath technique. Gastroenterol. 1984;86:714–720. 61. Kocoshis SA, Schletewitz K, Lovelace G, Laine RA. Duodenal bile acids among children: keto derivatives and aerobic small bowel bacterial overgrowth. J Pediatr Gastroenterol Nutr. 1987;6:686–696. 62. Shah SC, Day LW, Somsouk M, Sewell JL. Meta-analysis: antibiotic therapy for small intestinal bacterial overgrowth. Aliment Pharmacol Ther. 2013;38(8):925–934. 63. Gupta K, Ghuman HS, Handa SV. Review of rifaximin: latest treatment frontier for irritable bowel syndrome mechanism of action and clinical profile. Clin Med Insights Gastroenterol. 2017;10:1179552217728905. 64. Di Stefano M, Malservisi S, Veneto G, et al. Rifaximin versus chlortetracycline in the short-term treatment of small intestinal bacterial overgrowth. Aliment Pharmacol Ther. 2000;14:551–556. 65. Lauritano EC, Gabrielli M, Scarpellini E, et al. Antibiotic therapy in small intestinal bacterial overgrowth: rifaximin versus metronidazole. Eur Rev Med Pharmacol Sci. 2009;13(2):111–116. 66. Pimentel M, Chang C, Chua KS, et al. Antibiotic treatment of constipation-predominant irritable bowel syndrome. Dig Dis Sci. 2014;59(6): 1278–1285. 67. Low K, Hwang L, Hua J, et al. A combination of rifaximin and neomycin is most effective in treating irritable bowel syndrome patients with methane on lactulose breath test. J Clin Gastroenterol. 2010;44(8):547–550. 68. Bjorneklett A, Hoverstad T, Hovig T. Bacterial overgrowth. Scand J Gastroenterol. 1985;109(suppl):123–132.

69. Lauritano EC, Gabrielli M, Scarpellini E, et al. Small intestinal bacterial overgrowth recurrence after antibiotic therapy. Am J Gastroenterol. 2008;103(8):2031–2035. 70. Gaon D, Garmendia C, Murrielo NO, et al. Effect of Lactobacillus strains (L. casei and L. acidophilus strains cereal) on bacterial overgrowth-related chronic diarrhea. Medicina (Brazil). 2002;62:159–163. 71. Rezaie A, Pimentel M, Rao SS. How to test and treat small intestinal bacterial overgrowth: an evidence-based approach. Curr Gastroenterol Rep. 2016;18(2):8. 72. Chedid V, Dhalla S, Clarke JO, et al. Herbal therapy is equivalent to rifaximin for the treatment of small intestinal bacterial overgrowth. Glob Adv Health Med. 2014;3(3):16–24. 73. Shapiro S, Meier A, Guggenheim B. The antimicrobial activity of essential oils and essential oil components towards oral bacteria. Oral Microbiol Immunol. 1994;9:202–208. 74. Logan AC, Beaulne TM. The treatment of small intestinal bacterial overgrowth with enteric-coated peppermint oil: a case report. Alt Med Rev. 2002;7:410–417. 75. Su T, Lai S, Lee A, et al. Meta-analysis: proton pump inhibitors moderately increase the risk of small intestinal bacterial overgrowth. J Gastroenterol. 2017;2. [Epub ahead of print]. https://doi.org/10.1007/s00535-017-1371-9. 76. Quartarone G. Role of PHGG as a dietary fiber: a review article. Minerva Gastroenterol Dietol. 2013;59(4):329–340. 77. Furnari M, Parodi A, Gemignani L, et al. Clinical trial: the combination of rifaximin with partially hydrolysed guar gum is more effective than rifaximin alone in eradicating small intestinal bacterial overgrowth. Aliment Pharmacol Ther. 2010;32(8):1000–1006. 78. Ploesser J, Weinstock LB, Thomas E. Low dose naltrexone: side effects and efficacy in gastrointestinal disorders. Int J Pharm Compd. 2010;14(2):171–173. 79. Pimentel M, Morales W, Lezcano S, et al. Low-dose nocturnal tegaserod or erythromycin delays symptom recurrence after treatment of irritable bowel syndrome based on presumed bacterial overgrowth. Gastroenterol Hepatol (NY). 2009;5(6):435–442. 80. Pimentel M, Constantino T, Kong Y, et al. A 14-day elemental diet is highly effective in normalizing the lactulose breath test. Dig Dis Sci. 2004;49(1):73–77. 81. Rao SS, Yu S, Fedewa A. Systematic review: dietary fibre and FODMAPrestricted diet in the management of constipation and irritable bowel syndrome. Aliment Pharmacol Ther. 2015;41(12):1256–1270. 82. Nucera C, Lupascu A, Gabrielli M, et al. Sugar intolerance in irritable bowel syndrome: the role of small bowel bacterial overgrowth. Gastroenterol. 2004;126(4 suppl 2):A511. 83. Gottschall E. Breaking the Vicious Cycle. Baltimore: Kirkton Press; 1994. 84. Chander Roland B, Mullin GE, Passi M, et al. A prospective evaluation of ileocecal valve dysfunction and intestinal motility derangements in small intestinal bacterial overgrowth. Dig Dis Sci. 2017;4. [Epub ahead of print]. https://doi.org/10.1007/s10620-017-4726-4.

10 Cell-Signaling Analysis Lise Alschuler, ND, and Aristo Vojdani*, PhD, MSc, CLS

OUTLINE Introduction, 118 The Cell Cycle, 118 Flow Cytometry to Assess Cell-Cycle Status, 119

Clinical Application, 119 Patients Exposed to Carcinogenic Chemicals and Patients With Chronic Fatigue Syndrome, 119

INTRODUCTION

from 2C to 4C. At the end of S, the cell duplicates its genome and now is in the tetraploid state. After the S phase, the cell again enters a phase that was historically thought to be quiescent. Because this phase is the second gap region, it is referred to as G2. In the G2 phase, the cell

Signaling pathways in normal cells consist of growth and control messages from the outer surface deep into the nucleus. In the nucleus, the cell-cycle clock collects different messages, which are used to determine when the cell should divide. Cancer cells often proliferate excessively because genetic mutations cause induction of stimulatory pathways and issue too many “go-ahead” signals, or the inhibitory pathways can no longer control the stimulatory pathways.1 Impressive evidence has now been gathered with regard to the destination of stimulatory and inhibitory pathways in the cell. These pathways converge on a molecular apparatus in the cell nucleus that is often referred to as the cell-cycle clock. The clock is the executive decision maker of the cell; apparently, it runs amok in virtually all types of human cancer. In a normal cell, the clock integrates the mixture of growth-regulating signals received by the cell and decides whether the cell should pass through its life cycle. If the answer is positive, the clock leads the process. 

Cell divides (mitosis) Cell prepares to divide G2

Beginning of the cycle M

G0

Cell enlarges and makes new protein

THE CELL CYCLE A schematic of the classic cell cycle is shown in Fig. 10.1. The cell-cycle compartments are drawn such that their horizontal position reflects their respective DNA content. Cells that contain only one complement of DNA from each parent (2C) are referred to as diploid cells. Cells that have duplicated their genome, and thus have 4C amounts of DNA, are called tetraploid cells. The cell cycle is classically divided into the following phases: • G0 • G1 • S • G2 • M The cell-cycle phase of G1 was historically considered to be a time when diploid (2C) cells had little observable activity. Because this time precedes DNA synthesis, the term Gap 1 (G1) was coined. It is known that there is quite a bit of transcription and protein synthesis during this phase. At a certain point in the cell’s life, the DNA synthetic machinery turns on. This phase of the cell’s life is labeled S for synthesis. As the cell proceeds through this phase, its DNA content increases *Previous edition contributor

118

Cell replicates its DNA

R

S

G1 Restriction point: Cell decides whether to commit to the complete cycle

A

Number of events

G0 + G1

S

B

2C

DNA

G2 + M 4C

FIG. 10.1  Stages of the cell cycle (G0, G1, S, G2, and M phases) (A) and DNA histogram (B) generated by flow cytometry.

CHAPTER 10  produces the necessary proteins that play a major role in cytokinesis. After a highly variable amount of time, the cell enters mitosis (M). DNA content remains constant at 4C until the cell actually divides at the end of telophase. The enlarged parent cell finally reaches the point where it divides in half to produce its two daughters, each of which is endowed with a complete set of chromosomes. The new daughter cells immediately enter G1 and may go through the full cycle again. Alternatively, they may stop cycling temporarily or permanently.2–4 Telomeres, condensed chromatin caps on the ends of chromosomes, dictate the ultimate number of cell divisions that can occur. With each cell division, the telomeres shorten, ultimately to the point that destabilizes the chromosomes sufficiently enough to disallow further mitosis. Thus telomeres are considered to be the “mitotic clock.” Telomere shortening is linked to aging, sedentarism, chronic stress, and age-related diseases, including cancer, coronary artery disease, and heart failure. Cell-proliferation capacity, the cellular environment, and epigenetic factors affect telomere length and therefore cells’ mitotic capacity. Telomere length can be assessed, and a clinical test is available. The telomere length is reported as a telomere score, which is a calculation of the telomere length derived from nucleated white blood cells. This result is then compared with the average telomere length of a similarly aged sample population. Although the transferability of this information to other bodily tissues is not well characterized, telomere length measured in this way has been correlated to clinical outcomes such as cancer incidence and mortality from cancer.5 This information can be used to prioritize interventions that increase telomere length, such as dietary interventions, stress reduction, and antioxidant and vitamin therapies.6 Another influence on the cell-cycle clock is circadian rhythms, or the circadian clock. The circadian clock is the result of molecular clocks in each cell, circadian physiology, and, ultimately, the suprachiasmatic nuclei in the hypothalamus. The circadian clock regulates the activity and expression of proteins related to cell-cycle checkpoints, and in turn these checkpoints regulate circadian-clock proteins. Every cell in the body has circadian-clock proteins, so-called peripheral oscillators, which exert rhythmic control of mitochondrial morphology, energy metabolism, and cell division.7 This has significant clinical implications, particularly in the area of cancer treatment. Both the toxicity and efficacy of cytotoxic agents can vary by more than 50% as a function of when they are dosed in experimental models.8 Although the clinical implications of this have not yet been discovered, the administration of cytotoxic agents in accordance with the circadian-induced activity of the target cells is gaining ground as a reasonable therapeutic approach. 

FLOW CYTOMETRY TO ASSESS CELL-CYCLE STATUS Flow cytometry identifies cells as they “flow” through a detector while being illuminated with intense light. Tissues are generally disaggregated into single-cell suspensions and stained with one or more fluorescent dyes. The cells are forced to flow within a sheath of fluid, eventually being intersected and interrogated by an intense light source, such as a laser beam. As the cell enters the laser beam, it scatters light in all directions. The measurement of light scattered in the forward direction yields information on the particle’s size. Scattered light at right angles to the incident light beam provides information on the internal granularity of the cell. If the cell has been stained with one or more fluorescent dyes, a correlated measurement of more than one cellular parameter can be achieved. The cell cycle is challenging to study because almost any method can cause perturbations to the activity under study. Newer methods to study the cell cycle allow the ability to assess the cell cycle in living cells.

Cell-Signaling Analysis

119

One such method involves labeling the subpopulations of living cells in each phase of the cell cycle with fluorescent proteins. Then, using imaging, one can track and quantify cells in specific phases of the cell cycle using these live cell sensors. This method avoids perturbations to the cell cycle from the test and also allows for the assessment of external influences on the cell cycle.9 

CLINICAL APPLICATION Patients Exposed to Carcinogenic Chemicals and Patients With Chronic Fatigue Syndrome To determine whether peripheral blood lymphocytes (PBLs) isolated from individuals with chronic fatigue syndrome (CFS) and chemically exposed patients represent a discrete block in cell-cycle progression, PBLs isolated from patients with CFS and control individuals were cultured, harvested, fixed, stained with propidium iodide, and analyzed by flow cytometry. The nonapoptotic cell population in PBLs isolated from individuals with CFS consisted of cells arrested in the late S and G2/M boundaries compared with healthy controls. The arrest was characterized by increased S and G2/M phases of the cell cycle (from 9%–33% and from 4%–21%, respectively) (Table 10.1 and Fig. 10.2) at the expense of G0/G1. Such an abnormality in cell-cycle progression indicates abnormal mitotic cell division in patients who have been exposed to chemicals and who have CFS. From these results,

TABLE 10.1  Percentage of Different Phases

of Cell Cycle in Healthy Controls and Patients Exposed to Chemicals Phase

Healthy Controls

Chemically Exposed

G0/G1 S G2/M

88.6 ± 1.4 8.6 ± 1.2 3.6 ± 0.82

51.7 ± 2.4 33.2 ± 4.3 21.0 ± 2.6

3.6 8.6

Cell cycle of health subject 88.6 G0/G1

A

S G2/M 21

Cell cycle of patients exposed to MTBE and benzene

51.7 33.2

B FIG. 10.2 Cell-cycle analysis of peripheral blood lymphocytes from healthy controls (A) and patients exposed to MTBE and benzene (B). Note that in patients’ samples, the majority of cells switched from G0/ G1 to S and G2/M phases.

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it was concluded that the PBLs of patients with chemical exposure and CFS grow inappropriately, not only because the signaling pathways in the cells are perturbed but also because the cell-cycle clock becomes deranged and stimulatory messages become greater than the inhibitory pathways.10,11 However, to limit cell proliferation and avoid cancer, the human body equips cells with certain backup systems that guard against runaway division. One such backup system present in the lymphocytes of patients with CFS provokes the cell to undergo apoptosis. This programmed cell death occurs if some of the cell’s essential

components are deregulated or damaged. For example, injury to chromosomal DNA can trigger apoptosis.1,10,11

REFERENCES See www.expertconsult.com for a complete list of references.

REFERENCES 1. Weinberg RA. How cancer arises. Sci Am. 1996;275:62–70. 2. Wheeless LL, Coon JS, Cox C, et al. Precision of DNA flow cytometry in inter-institutional analyses. Cytometry. 1991;12:405–412. 3. Wersto RP, Liblit RL, Koss LG. Flow cytometric DNA analysis of human solid tumors: a review of the interpretation of DNA histograms. Hum Pathol. 1991;22:1085–1098. 4. Shankey TV, Rabinovitch PS, Bagwell B, et al. Guidelines for implementation of clinical DNA cytometry. Cytometry. 1993;14:472–477. 5. Willeit P, Willeit J, Mayr A, et al. Telomere length and risk of incident cancer and cancer mortality. JAMA. 2010;304(1):69–75. 6. Xu Q, Parks CG, DeRoo LA, et al. Multivitamin use and telomere length in women. Am J Clin Nutr. 2009;89(6):1857–1863. 7. Schmitt K, Grimm A, Dallmann R, et al. Circadian control of DRP1 activity regulates mitochondrial dynamics and bioenergetics. Cell Metab. 2018;27(3):657–666.

8. Lévi F, Focan C, Karaboué A, et al. Implications of circadian clocks for the rhythmic delivery of cancer therapeutics. Adv Drug Deliv Rev. 2007;59(9– 10):1015–1035. 9. Henderson L, Bortone DS, Lim C, Zambon AC. Classic “broken cell” techniques and newer live cell methods for cell cycle assessment. Am J Physiol Cell Physiol. 2013;304(10):C927–C938. 10. Vojdani A, Ghoneum M, Choppa PC, et al. Elevated apoptotic cell population in patients with chronic fatigue syndrome: the pivotal role of protein kinase RNA. J Intern Med. 1997;242:465–478. 11. Vojdani A, Mordechai E, Brautbar N. Abnormal apoptosis and cell cycle progression in humans exposed to methyl tertiary-butyl ether and benzene contaminating water. Human Exp Toxicol. 1997;16:485–494.

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11 Erythrocyte Sedimentation Rate Michael T. Murray, ND

OUTLINE Introduction, 121 Erythrocyte Aggregation, 121 Procedures, 121 Westergren Method, 122 Wintrobe Method, 122

Results, 122 Interpretation, 122 Elevated Erythrocyte Sedimentation Rate, 122 Monitoring of Disease Activity, 123 Summary, 124

INTRODUCTION

infectious processes, especially when variables such as anemia confound the ESR. The ESR is also elevated in patients with proteinemias (myeloma, macroglobulinemia, cryoglobulinemia, and cold agglutinin disease).1–4 Disorders of erythrocytes such as various anemias will alter the ESR and may interfere with accurate interpretation.1–4 Because the ESR is directly proportional to the mass of the erythrocyte and inversely proportional to its surface area, large erythrocytes sediment more rapidly than smaller cells. Therefore in macrocytic anemia, there is an increased ESR, and in microcytic anemia, there is a decreased ESR. Although the usefulness of ESR determination has decreased as new methods of evaluating disease have been developed, it remains quite helpful in the diagnosis of some diseases, such as temporal arteritis and polymyalgia rheumatica. Perhaps more useful is its ability to monitor these conditions and others, including chronic inflammatory diseases such as rheumatoid arthritis (RA), Hodgkin disease, and other cancers. Although the use of the ESR as a screening test to identify patients who have serious disease is not supported by the literature, it does provide a general gauge of inflammatory processes in the body. It is well accepted that an extreme elevation of the ESR is strongly associated with serious underlying disease, most often infection, collagen vascular disease, or metastatic malignancy. Recently there has been a growing appreciation of the value of the ESR as a marker for atherosclerosis and coronary artery disease.5,6 In addition, as a sign of chronic low-grade inflammation, it may be helpful as a marker for other conditions as well. For example, in a study of 49,321 Swedish males aged 18 to 20 years, screened for general health and for mental and physical capacity at compulsory conscription examination before military service, there was an inverse correlation between ESR and performance on an IQ test.7 This result indicated that low-grade inflammation, as indicated by the ESR, was associated with reduced cognitive abilities at ages 18 to 20 years. 

The erythrocyte sedimentation rate (ESR), the rate at which erythrocytes settle out of nonclotted blood in 1 hour, has been one of the most widely performed laboratory tests in the past 75 years. Used primarily to detect occult processes and monitor inflammatory conditions, the ESR test has changed little since 1918 when Fahraeus discovered that the erythrocytes of pregnant women sedimented in plasma more rapidly than they did in nonpregnant women. Since its incorporation into standard laboratory diagnosis, the ESR has been shrouded in medical myths and is often misinterpreted or misused. This chapter provides rational guidelines for its use as a nonspecific measure of inflammatory, infectious, neoplastic, and cardiovascular diseases.1–4 

ERYTHROCYTE AGGREGATION Normally, erythrocytes settle quite slowly as the gravitational force of the erythrocyte’s mass is counteracted by the buoyant force of the erythrocyte’s volume. However, when erythrocytes aggregate, they sediment relatively rapidly because the proportional increase in their total mass exceeds the proportional increase in their volume. Therefore the major determinant in the sedimentation rate of erythrocytes is erythrocyte aggregation, which usually occurs along a single axis (rouleaux formation). The aggregation of erythrocytes is largely determined by electrostatic forces. Under normal circumstances, erythrocytes have a negative charge and therefore repel each other. However, many plasma proteins are positively charged and neutralize the surface charge of erythrocytes, thereby reducing repulsive forces and promoting aggregation. The relative contribution of the various “acute-phase” reactant proteins to aggregation is shown in Table 11.1. One protein that has no direct effect on the ESR in physiologic concentrations but is associated with certain inflammatory, degenerative, and neoplastic diseases is C-reactive protein (CRP). Its major function is facilitation of the complement system. Like ESR, the measurement of CRP is used in the monitoring of patients with chronic inflammatory conditions.1,2 An elevated CRP provides evidence of an inflammatory process despite a normal ESR. Therefore, when used in conjunction with the ESR, it greatly increases the sensitivity in detecting inflammatory and/or

PROCEDURES Various methods for determination of the ESR have been developed. Currently, the Westergren method is recommended by the International Committee for Standardization in Hematology.

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TABLE 11.1  Relative Contribution of

Acute-Phase Reactant Proteins to Erythrocyte Aggregation Blood Constituent Fibrinogen β-Globulin α-Globulin Albumin

Relative Contribution 10 5 2 1

BOX 11.1  Results of Westergren and

Wintrobe Methods • Westergren (normal results) • Men: 0 to 10 mm/h • Women: 0 to 15 mm/h • Children: 0 to 10 mm/h • Wintrobe (normal results) • Men: 3000 mg Na/24 h • Salt-restricted diet: 2300 mg Na/24 h (or less) 

INTERPRETATION The results of a Fantus test generally reflect the salt content of the diet. The typical Western diet contains 3.4 g of sodium in a 24-hour period. On a salt-restricted diet, the goal is typically to reduce 24-hour urine sodium to 2.3 g Na/24 h or less. The minimum 24-hour sodium intake considered safe is 0.5 g Na/24 h for healthy individuals with intact adrenocortical function. Some conditions require higher sodium chloride intake (see Table 12.1). A random urine can be tested for urine sodium with the Fantus test and can give an approximation of 24-hour sodium ingestion. A sodium intake of 3.4 g Na/day with an intake of 2750 mL of water from both solids and fluids corresponds to the average water turnover for a 70-kg adult. After evaporation from the lungs and other losses, the amount of water excreted by the kidneys is approximately 1500 mL/24 h.33 A urinary sodium excretion of 3 g in 24 hours would thus produce a urinary sodium concentration of 2 g/L and a urinary sodium chloride concentration of 5.1 g/L (NaCl). A 24-hour urine sample provides a more accurate estimate of 24-hour sodium intake (i.e., 24-hour urine volume × urinary sodium concentration approximates 24-hour sodium intake).

REFERENCES See www.expertconsult.com for a complete list of references.

REFERENCES 1. DeGowin E, DeGowin RI. New York, NY: Macmillan; 1969:37. 2. Luft FC, Fineberg NS, Sloan RS. Overnight urine collections to estimate sodium intake. Hypertension. 1982;(4):494–498. 3. Taylor WH. Use and interpretation of the Fantus estimation of urinary chloride. Med J. 1951;2(4740):1125–1128. PMID:14869835. 4. Fantus JB. Fluid postoperatively: statistical study. JAMA. 1936;107:14. 5. Marriott H. Water and salt depletion. Br Med J. 1947;1:328. 6. Ambard L, Beaujard E. Causes de l’hypertension arteriole. Arch Gen Med. 1904;1:520–533. 7. Kempner W. Treatment of kidney disease and hypertensive vascular disease with rice diet. III. North Carolina Med J. 1945;6(61–87):117–161. 8. Grohman A, Harrison T, Mason M, et al. Sodium restriction in the diet for hypertension. JAMA. 1945;129:533–537. 9. Chapman CB, Gibbons T, Henschel A. The effect of the rice-fruit diet on the composition of the body. N Engl J Med. 1950;243:899–905. 10. Dustan HP, Bravo EL, Tarazi RC. Volume-dependent essential and steroid hypertension. Am J Cardiol. 1973;31:606–615. 11. Dustan HR, Tarazi RC, Bravo EL. Diuretic and diet treatment of hypertension. Arch Intern Med. 1974;133:1007–1013. 12. Parijs J, Joossens JV, Van der Linden L, et al. Moderate sodium restriction and diuretics in the treatment of hypertension. Am Heart J. 1973;85:22–34. 13. American Heart Association. Changes You Can Make to Manage High Blood Pressure. 2017. 14. Kotchen TA, Kotchen JM. Dietary sodium and blood pressure: interactions with other nutrients. Am J of Clin Nutr. 1997;65(suppl 2):708S–711S. 15. Kurtz T, Morris R. Dietary chloride as a determinant of sodium-dependent hypertension. Science. 1983;222:1139–1141. 16. Sanghavi S, Vassaldotti JA. Dietary sodium: a therapeutic target in the treatment of hypertension and CKD. J Ren Nutr. 2013;23(3):223–227. PMID:23611551. 17. Pizzorno J1, Frassetto LA, Katzinger J. Diet-induced acidosis: is it real and clinically relevant? Br J Nutr. 2010;103(8):1185–1194. 18. Institute of Medicine. Dietary Reference Intakes for Water, Potassium, Sodium Chloride, and Sulfate. Washington, DC: National Academies Press; 2004.

19. Institute of Medicine. Dietary Reference Intakes for Water, Potassium, Sodium Chloride, and Sulfate. Washington, DC: National Academies Press; 2004. 20. Aburto NJ, Das S. Effect of Reduced Sodium Intake on Blood Pressure, Renal Function, Blood Lipids and Other Potential Adverse Effects. Geneva, Switzerland: World Health Organization; 2012. 21. Cogswell ME, Mugavero K, Bowman BA, Frieden TR. Dietary sodium and cardiovascular disease risk- measurement matters. N Engl J Med. 2016;375:580–586. 22. He FJ, Li J, MacGregor GA. Effect of longer-term modest salt reduction on blood pressure. Cochrane Database Syst Rev. 2013;4:CD004937. 23. Palar K, Sturm R. Potential societal savings from reduced sodium consumption in the U.S. adult population. Am J Health Promot. 2009;24(1):49– 57. 24. Harnack LI, Cogswell ME, Shikany JM, et al. Sources of sodium in U.S. adults from 3 geographic regions. Circulation. 2017;135:1775–1783. 25. U.S. Department of Health and Human Services, U.S. Department of Agriculture. What we eat in America. NHANES. 2013–2014, Table 37.1017. 26. U.S. Department of Health and Human Services, U.S. Department of Agriculture. 2015-2020 Dietary Guidelines for Americans. 2015. 27. Meneely GR, Batterbee HD. High sodium-low potassium environment and hypertension. Am J Cardiol. 1976;38:768–785. 28. Khairallah P, Sen S, Tarazi R. Angiotensin, protein biosynthesis and cardiovascular hypertrophy (abstr). Am J Cardiol. 1976;37:148. 29. Tobian L, Ishii M, Duke M. Relationship of cytoplasmic granules in renal papillary interstitial cells to “post-salt” hypertension. J Lab Clin Med. 1969;73:309–319. 30. Dahl LK. Effects of chronic excess salt feeding. Induction of self-sustaining hypertension in rats. J Exp Med. 1961;114:231–236. 31. Scribner BH. Salt and hypertension. JAMA. 1983;250:388–389. 32. De Lorenzo F, Hargreaves J, Kakkar VV. Pathogenesis and management of delayed orthostatic hypotension in patients with chronic fatigue syndrome. Clin Auton Res. 1997;7(4):185–190. PMID: 9292244. 33. Marriott H. Water and salt depletion. Br Med J. 1947;1:328.

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13 Fatty Acid Profiling Patricia M. Devers, DO, and Warren M. Brown, ND

OUTLINE Introduction, 127 Structure and Nomenclature, 127 Measurement, 128 Clinical Significance of Results, 129 Omega-3 (n-3) Polyunsaturated Fatty Acids, 129 Omega-6 (n-6) Polyunsaturated Fatty Acids, 130

INTRODUCTION Dietary fat intake and its emerging role in chronic disease highlight the need for proper fatty acid measurement and profiling. Many studies have implicated fatty acid imbalances in various conditions,1–8 including: • Cardiovascular disease • Chronic inflammatory conditions • Neurological and psychiatric disease • Cancer • Diabetes • Polycystic ovary syndrome • Chronic obstructive pulmonary disease • Asthma Unlike other macronutrients, fat is one of the most difficult dietary intake components to quantify. Patients often misreport their fat intake, and food composition tables are frequently incorrect. There is no single biomarker to assess total dietary fat intake.9 Although the body digests dietary fat into fatty acids, measuring fatty acids cannot validate fat intake because some fatty acids do not come from the diet and are endogenously made. However, there are some biomarkers that reflect essential fatty acid consumption and others that reflect endogenously produced fatty acids. To interpret these measurements, it is important to first understand the definition, physiology, and metabolism of fatty acids. Fatty acids are simple in structure: a carbon backbone with a carboxyl group (COO) at one end and a methyl group (CH3) at the other. They function as energy-storage units, cell membrane structural units, and eicosanoid precursors. Dietary fats are digested into fatty acids, which are then absorbed into the circulation. Three fatty acids can join with glycerol to form triglyceride molecules. Fatty acids are found in serum, cell membranes, and adipocytes. Although there are many fatty acid dietary sources, such as olive oil and fish, some food sources are more critical than others. The term essential fatty acid means these are essential for life and must come from the diet. There are only two essential fatty acids: alpha-linolenic acid (ALA) and linoleic acid (LA). ALA is found in foods such as flax,

Monounsaturated Fatty Acids, 130 Trans Fatty Acids, 131 Saturated Fatty Acids, 131 Fatty Acid Ratios, 132 Summary, 132

chia, walnuts, and unhydrogenated soybean oil.10,11 LA food sources include sunflower seeds, corn oil, and nuts.12 Besides essential dietary fatty acids, there are fatty acids that are made endogenously. The body makes them using three processes: synthesis, elongation, and desaturation. First, fatty acids can be synthesized from acetyl coenzyme A (acetyl-CoA) units made from dietary carbohydrate digestion and metabolism. Insulin’s lipogenic activity allows excess glucose to be converted into triglycerides in the liver. Hence, triglycerides and fatty acids can be made through carbohydrate metabolism.13 Next, fatty acids can be formed using elongase and desaturase enzymes. Some endogenous fatty acids are formed by adding carbons to dietary fatty acid backbones: they are elongated by elongase enzymes. In desaturation, some of the single bonds in the carbon backbone are converted to double bonds. Desaturation enzymes create different fatty acids9,14 (Fig. 13.1). 

STRUCTURE AND NOMENCLATURE As mentioned previously, fatty acids are simple in structure: a carbon backbone with a carboxyl group (COO) at one end and a methyl group (CH4) at the other. The methyl group is labeled omega (ω). When profiling fatty acids, nomenclature can be complex. In general, they are designated based on the length of the carbon atom backbone, the number of double bonds, and the first double bond’s distance from the carbon chain opposite the carboxyl group.9,15 The fatty acid backbone usually ranges between 6 and 22 carbons in length, sometimes longer. Because of the variation in the carbon atom backbone members, fatty acids are categorized as short-chain, medium-chain, long-chain, and very-long-chain fatty acids. Fatty acids are also classified by a double bond’s presence or absence, which determines their saturation degree. Saturated fatty acids have no double bonds. Unsaturated fatty acids have one or more double bonds between carbon atoms. Because fatty acids are necessary for forming cell membranes, saturation can play a role in cell membrane fluidity. Monounsaturated fatty acids (MUFAs), found in olive oil and avocados, have one carbon-carbon double bond, which can occur at

127

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Omega-3 FA α-linolenic Acid (ALA) Stearidonic Acid Eicosatetraenoic Acid Eicosapentaenoic Acid (EPA) Docosapentaenoic Acid Tetracosapentaenoic Acid Tetracosahexaenoic Acid Docosahexaenoic Acid (DHA)

Omega-6 FA

Omega-9 FA

∆ 6 desaturase

Linoleic Acid (LA)

elongase

γ-linoleic Acid (GLA)

elongase

∆ 5 desaturase

Dihomo-γ-linoleic Acid (DGLA)

∆ 5 desaturase

elongase

Arachidonic Acid (AA)

elongase

∆ 6 desaturase

6-oxidation

∆ 6 desaturase

Oleic Acid (OA) Octadecadienoic Acid Eicosadienoic Acid Eicosatrienoic Acid (Mead Acid)

Docodatetraenoic Acid Tetracosatetraenoic Acid Tetracosapentaenoic Acid Docosapentaenoic Acid

Fig. 13.1  Fatty acid metabolism, elongation and desaturation of essential fatty acids. Chang MI, Puder M, Gura KM. The use of fish oil lipid emulsion in the treatment of intestinal failure associated liver disease (IFALD). Nutrients. 2012;4(12):1828 -1850.

different positions within their carbon backbone. The double-bond position designates its name. The most common MUFA is oleic acid, which is found in olive oil. It has a double bond at the ninth carbon and is therefore an omega-9 fatty acid (ω-9). Polyunsaturated fatty acids (PUFAs), found in foods such as salmon and sunflower seeds, contain more than one double bond. In PUFAs, the first double bond may be found between the third and fourth carbon atom from the ω; these are called omega-3 fatty acids (ω-3). If the first double bond is between the sixth and seventh carbon atoms, then they are called omega-6 fatty acids (ω-6).15 It is important to note that some laboratories denote omega using the letter n. For example, omega-3 fatty acids may also be reported as n-3. If the hydrogen atoms on either side of the double bond are in the same configuration, it is termed a cis configuration. Most fatty acids are in the cis configuration. When the hydrogen atoms change configuration, they are considered trans. Trans isomers may be induced during industrial processing of unsaturated oil or found in the gastrointestinal (GI) tracts of ruminant animals (cattle, sheep, goats, and deer). Trans fatty acids produced by industrial processing, such as partially hydrogenated vegetable oil, have been shown to cause endothelial dysfunction and may affect cardiovascular risk factors. Ruminant trans fats, as found in dairy products, may be beneficial.16,17 In fatty acid profiling, it is important to understand this nomenclature because the abbreviations can vary depending on the laboratory used. For example, stearic acid is a saturated fatty acid with 18 carbons and no double bonds (18:0), whereas oleic acid has 18 carbon bonds and one double bond in the n-9 position (18:1n9). Additionally, eicosapentaenoic acid (EPA) has 20 carbons and multiple double bonds and is represented as 20:5n3. This numerical scheme is the systematic nomenclature commonly used by clinical laboratories. It is also possible to describe fatty acid double bonds in relation to the carbon chain’s acidic end, symbolized as delta (Δ). Hence, EPA can also be represented as 20:5 Δ5,8,11,14,17. 

MEASUREMENT Monitoring a patient’s fatty acid status offers a way to target dietary therapeutics and alter disease progression. For this reason, usual or long-term dietary intake markers are important. Fatty acids can be measured as free fatty acids in serum, as erythrocyte membrane components, or in adipose tissue. Adipose tissue fatty acid measurement estimates fatty acid intake ranging from 6 months to 2 years.18 It is therefore the most ideal reflection of dietary patterns. However, adipose tissue biopsy is not practical. Plasma and erythrocyte assessments are more commonly used because of the ease of specimen collection. Because the life of a red blood cell averages 90 to 120 days, erythrocyte fatty acid assessment is more reflective of long-term status and is therefore preferred to plasma evaluation.18 For example, omega-3 plasma levels have been shown to be influenced by an acutely high fish oil dose or a short-term dietary increase.19 Fatty acid biomarkers are sometimes validated by examining the correlation with measured dietary fat intake. Saturated and monounsaturated fatty acid measurements may not always reflect dietary fat intake because these can be endogenously synthesized from carbohydrates.20 Erythrocyte fatty acids are reported as a percentage in the red blood cell (RBC) membrane. When dealing with RBC percentages, one must realize that each fatty acid has an effect on the other percentages. For example, fish oil supplementation (n-3) may increase the overall n-3 percentage, which by default may lower the n-6 percentage. Plasma measurements are expressed as a percentage or absolute total lipid volume concentration. Again, the percentages are interdependent on the whole. After an omega-3 dose, the peak concentration can be observed at 6 hours, whereas the peak percentage can be seen at 24 hours. Plasma-based metrics can be sensitive to fasting status and acute intake. In general, RBC-based metrics are more stable over time.21 

Fatty Acid Profiling

CHAPTER 13 

Stearic 18:0

18

methyl

H3C

trans-Oleic 9t-18:1

H3C

Linoleic (LA) 9c, 12c-18:2 (18:2n–6)

H3C

α-Linolenic (ALA) 9c, 12c, 15c-18:3 (18:3n–3) Arachidonic (AA) 5c, 8c, 11c, 14c-20:4 (20:4n–6)

1 COOH

H3C

cis-Oleic 9c-18:1 (18:1n–9)

129

carboxyl 9

18

H

H

H

18

1 COOH

1 COOH

9 H

18

18

H3C

15

12

9

1 COOH

12

9

1 COOH

20

H3C

Eicosapentaenoic (EPA) 20 5c, 8c, 11c, 14c, 17c-20:5 H3C (20:5n–3)

17

14

11

8

5

1 COOH

14

11

8

5

1 COOH

Docosahexaenoic (DHA) 4c, 7c, 10c, 13c, 16c, 1 19 16 13 10 7 4 22 COOH 19c-22:6 H3C (22:6n–3) Fig. 13.2  Common dietary fatty acids. Structures of some common dietary fatty acids. Ratnayake W, M, N, Galli C: Fat and Fatty Acid Terminology, Methods of Analysis and Fat Digestion and Metabolism: A Background Review Paper. Ann Nutr Metab 2009;55:8–43. https://doi.org/10.1159/000228994

CLINICAL SIGNIFICANCE OF RESULTS See Fig. 13.2.

Omega-3 (n-3) Polyunsaturated Fatty Acids Omega-3 fatty acids are positively correlated with healthy aging throughout life and are essential for brain function and cardiovascular health. The average American diet is deficient in n-3 food sources such as oily fish, nuts, flax, and green leafy vegetables. Deficiencies in n-3 fatty acids can result in neurodevelopmental and behavioral disorders, visual changes, skin abnormalities, and heart disease.22–26 Many studies show that n-3 fatty acids have significantly positive effects on infant development, cancer, cardiovascular disease, depression, attention deficit hyperactivity disorder, and cognitive decline. These health benefits are mediated through several different mechanisms, including alterations in cell membrane composition and function, anti-inflammatory effects, gene expression, and eicosanoid production.27 • Alpha-linoleic acid (ALA) is an essential n-3 fatty acid that must be supplied from the diet. From ALA, other important n-3 fatty acids can be endogenously produced by enzymatic elongation and desaturation. ALA is the 18-carbon, 3-double-bond (18:3n3) precursor to make eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA), although these are also found in fish oils. ALA dietary sources include green leafy vegetables, walnuts, chia, hemp, and certain plant oils like flaxseed oil and unhydrogenated soybean oil. Several studies on high dietary intake of ALA and higher ALA blood levels show an association with lower fatal coronary artery disease risk.11 However, there are significant variations in genetics,

nutrition, and toxin load that greatly affect an individual’s ability to make this multistep conversion. • Eicosapentaenoic acid (EPA) is an omega-3 fatty acid with a 20-carbon chain and five cis-double bonds (20:5n3). It can be enzymatically converted from ALA; however, the efficiency of enzymatic conversion is much lower compared with the absorption from EPA-containing foods. EPA can be obtained by eating oily fish such as cod, mackerel, salmon, and sardines. It is also available in fish oil supplements. EPA acts as a precursor for prostaglandin-3 (which inhibits platelet aggregation), thromboxane-3, and leukotriene-5 eicosanoids. EPA has beneficial effects on multiple atherosclerotic and inflammatory processes, including endothelial function, oxidative stress, foam cell formation, inflammatory cytokine production and release, plaque formation/progression, platelet aggregation, thrombus formation, and plaque rupture. EPA also reduces atherogenic dyslipidemia and has other beneficial effects arising from its inclusion in membrane phospholipids.28 • Docosapentaenoic acid (DPA) is made by adding carbons to the backbone of EPA using the enzyme delta-5 elongase. It is an intermediary product between EPA and docosahexaenoic acid (DHA) and can retro-convert back to EPA. It is denoted as 22:5n3. Relatively little is known about the potentially distinct DPA health benefits. Although small amounts are found in seafood, it is more often synthesized from EPA.29 • Docosahexaenoic acid (DHA) is a DPA metabolite with 22 carbons and six double bonds (22:6n3). DHA’s endogenous synthesis from its precursor is extremely low, so measured levels largely reflect

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seafood consumption or fish oil supplementation. Fish oil supplementation is commonly a combination of purified EPA and DHA. Cardiovascular disease researchers have studied seafood consumption and fish oil supplementation for both disease prevention and treatment. Fish oil supplementation has been shown to improve serum lipid levels. It prevents cardiac dysrhythmias by increasing cardiac cell membrane fluidity and prevents inflammatory cytokines from binding to their receptors.27 In cardiovascular risk assessment, the Omega-3 Index has emerged as an important biomarker in stratifying patients for targeted therapeutics. The Omega-3 Index is the sum of EPA + DHA percentages in RBCs. A target of >8% is optimal, whereas less than 4% denotes increased cardiovascular risk. Fish oil supplementation and dietary changes using fish, flax, chia, and walnuts are often used as therapeutic interventions. EPA and DHA are also important in fetal brain development. DHA levels positively correlate with the cognitive and retinal development of the fetus.27 Additionally, there is a role for n-3 in cancer prevention. Diets rich in n-3 (fish oil, flaxseed) and high n-3 erythrocyte concentrations are inversely related to colorectal and breast cancer development, likely due to n-3’s anti-inflammatory properties.27 

Omega-6 (n-6) Polyunsaturated Fatty Acids Omega-6 fatty acids play a vital role in many physiological functions. They are particularly important for maintaining bone health, regulating metabolism, and stimulating hair and skin growth. In spite of this, n-6 fatty acids are controversial. The current standard American diet reflects a higher n-6 intake compared with n-3. Dietary sources include vegetable oils and animal fats. Many human evolutionary diets had a 1:1 dietary ratio of n-3:n-6. The fatty acid intake dietary shift toward n-6 sources associated with the cultivation of food and feeding corn to livestock has been implicated in recent increases in disease.30 The issues surrounding n-6 fatty acids include potentially proinflammatory effects, their increased susceptibility to oxidation, and their competition with the n-3 fatty acids for the enzymatic elongation and desaturation pathways. Most of the concern regarding n-6 effects revolves around one of its downstream metabolites: arachidonic acid (AA). AA is the primary precursor in the inflammatory cascade. However, AA is not the only n-6 metabolite, and other n-6 fatty acids can be beneficial. For example, dihomo-gamma linoleic acid (DGLA) is a downstream n-6 fatty acid with many anti-inflammatory benefits. Additionally, linoleic acid has shown significant benefits for cardiovascular risks. • Linoleic acid (LA) is an essential n-6 and denoted as 18:2n6. It is the predominant n-6 in the Western diet, obtained mainly from vegetable oils and nuts. Higher LA intake has been shown to reduce low-density lipoprotein cholesterol, promote insulin sensitivity, and reduce hypertension risk. There is a significant inverse relationship between dietary LA intake and coronary artery disease when using LA to replace dietary carbohydrates and/or saturated fats.12 • Gamma linolenic acid (GLA) is classified as 18:3n6. It can be produced from the essential LA using the enzyme delta-6 desaturase. This is a very slow enzymatic reaction that is further restricted by systemic inflammation, acute and chronic disease, and vitamin and mineral deficiencies such as zinc and cobalt deficiencies.31 However, GLA can be supplemented using black currant, borage oil, and evening primrose. GLA levels are important because GLA is the direct precursor to produce dihomo-gamma linolenic acid (DGLA), which is a highly beneficial and anti-inflammatory n-6. GLA supplementation is rapidly metabolized to form DGLA and therefore is a common therapeutic

intervention.32 However, GLA supplementation can also increase the downstream metabolite AA.8 Supplementing fish oils (EPA/DHA) along with GLA may mitigate this downstream AA conversion because of enzymatic competition for the delta-5-desaturase enzyme. Delta-5desaturase is responsible for both AA production and EPA metabolism. • Dihomo-gamma-linolenic acid (DGLA), 20:3n6, has no significant dietary source (very small amounts can be found in some animal products) and is only metabolized from GLA. Research has confirmed that the inability to convert precursor fatty acids to DGLA is associated with many conditions, including diabetes, cancer, and cardiovascular disease.33 DGLA exerts anti-inflammatory effects when it is metabolized into eicosanoids and prostaglandins. These two oxidative DGLA metabolites have shown clinical efficacy by suppressing chronic inflammation, lowering blood pressure via vasodilation, inhibiting smooth muscle proliferation associated with atherosclerotic plaque development, arresting cancer cell growth, and aiding in tumor cell differentiation.33 • Arachidonic acid (AA), 20:4n6, is a downstream LA metabolite. There are also preformed AA dietary sources, such as animal fats, eggs, poultry, organ meats, and fish. AA is stored in cell membranes and released in response to injury. After AA release, it can be metabolized into eicosanoids through four different pathways: cyclooxygenase, lipoxygenase, cytochrome P450, and oxygen-species–triggered reactions. These pathways yield prostaglandins, isoprostanes, thromboxane, leukotrienes, lipoxins, and epoxyeicosatrienoic acids. Each can act to promote the inflammatory cascade.34 AA-derived eicosanoids have important roles in immunopathology and have been implicated in inflammation, autoimmunity, allergic diseases, and cancer.35 

Monounsaturated Fatty Acids MUFAs are different from other fatty acids because they have only one double bond in their carbon chain. The carbon atom number making up the backbone and the position of this double bond distinguishes one from another and changes their nomenclature. For example, if the double bond is in the seventh position on the carbon backbone, it is known as an omega-7 fatty acid. The most common dietary MUFA sources are olive oil and nuts. Diets rich in MUFAs have shown beneficial effects on total cholesterol, low-density lipoprotein (LDL) cholesterol, and high-density lipoprotein (HDL) cholesterol. MUFA diets have been shown to reduce LDL oxidative susceptibility, decrease platelet aggregation, increase fibrinolysis, and increase bleeding time.36 The mechanism involved in MUFAs’ health benefits is still being investigated. However, it has been proposed that changes in the composition of very-low-density lipoprotein (VLDL), VLDL enzymes, and VLDL proteins involved in VLDL catabolism decrease plasma triacylglycerol concentrations. Therefore the rates of VLDL production and triacylglycerol clearance may be altered because of dietary fat type and amount.36 • Oleic acid (OA) has an 18-carbon backbone with one double bond at the ninth carbon. Therefore it is known as an omega-9 fatty acid, 18:1n9. Olive oil is the main source of OA, which is the most represented MUFA in the diet. OA has attracted much attention because of the wide array of literature extolling the “Mediterranean diet,” which is rich in olive oil and nuts. Oleic acid has been shown to reduce saturated fatty acids’ inflammatory effects on endothelial cells due to a dampening of cytokine activation.37,38 • Nervonic acid (NA) is an important omega-9 fatty acid, 24:1n9. NA can be found in small amounts in borage and vegetable oils, but mainly it is an oleic acid elongation product.39 It is abundant in the brain’s white matter and necessary for nerve-cell myelin biosynthesis. NA is essential for brain growth and the maintenance of

CHAPTER 13  peripheral nervous tissue enriched with sphingomyelin.40 Alterations in NA plasma levels have been implicated in mood disorders and demyelinating disorders. Nervonic acid supplementation may also mitigate diabetic neuropathy.41 • Palmitoleic acid (PA) is a monounsaturated omega-7 fatty acid, 16:1n7. The main PA dietary sources are dairy products and macadamia nuts. However, PA can also be synthesized from triglyceride breakdown or de novo from surplus carbohydrates. Dairy products are rich in the trans isomer of PA, whereas macadamia nuts contain the cis isomer. In some studies, the trans isomer from dairy has been associated with less inflammation and lower diabetes risk than other trans fats. PA is involved in insulin sensitivity by exerting distinct effects on insulin signaling and glucose uptake.42 Macadamia nuts are associated with improving lipid profiles. However, whether the lipid-lowering effects are due to PA specifically, or other oils or nutrients found in these nuts, remains uncertain.42 • Vaccenic acid (VA) is a monounsaturated omega-7 fatty acid that is also classified as a trans fatty acid (trans-11-18:1n7). It is a positional and geometric isomer of oleic acid. Unlike trans fatty acids produced industrially, VA is naturally occurring. It is formed when saturated fatty acids are bacterially fermented in the GI tracts of ruminant animals (cattle, sheep, and goats). Dairy products (cheese, milk, butter) and meat from these animals contain VA.43 Although animal and cell studies suggest that VA may be lipid lowering and antiatherogenic, human studies are limited. 

Trans Fatty Acids Trans fatty acids (TFAs) are unsaturated fatty acids with at least one double bond in the trans configuration. There are two primary dietary trans fat sources: naturally occurring TFAs and industrially produced TFAs. Naturally occurring TFAs are consumed in meats and dairy products from cows, sheep, goats and other ruminant animals. As noted previously, these ruminant trans fats are produced through bacterial metabolism in the animal’s GI tract.44 But the more common dietary source in the American diet is industrially formed TFAs, as formed in vegetable oil’s hydrogenation or partial hydrogenation. The hydrogenation process converts vegetable oils into semisolid fats for use in margarines, commercial cooking, and manufacturing processes. These hydrogenated oils are increasingly used to improve grocery shelf life, increase vegetable oil stability during deep frying, and enhance taste in baked goods. The major TFA sources in the American diet are deep-fried fast foods, bakery products, packaged snack foods, and margarines.17 In recent years, TFAs’ dietary implications in public health have received increasing attention. The U.S. Food and Drug Administration (FDA) ruled, effective January 1, 2006, that the nutrition labels for all conventional foods and supplements must indicate trans fatty acid content. This was prompted by the evidence that trans fats promote inflammation and increase coronary heart disease risk. Trans fats also increase triglycerides, increase Lp(a) levels, and reduce LDL particle size.17 • Elaidic acid (EA) is an oleic acid trans isomer (trans-9-18:1). It is the predominant trans fatty acid in the Western diet. EA is found in margarine, partially hydrogenated vegetable oils, and fried foods. EA, like all TFAs, has been extensively studied for its role in increasing cardiovascular risk and adversely affecting lipid profiles. Additionally, EA has recently been shown to enhance metastatic cancer progression.45 • Vaccenic acid (VA), as noted previously, is a monounsaturated omega-7 trans fatty acid. It is formed in ruminant animals’ GI tracts and consumed in the diet as butter, cheese, and meats from

Fatty Acid Profiling

131

these animals. Although, as with all TFAs, increased VA intake and elevated levels increase risk, there is evidence that VA shows some health benefit in rodent and animal studies, although human studies are limited.16 VA’s metabolic fate has not been extensively studied. It is well absorbed from the diet, but from there, it is either rapidly oxidized or metabolized to other lipids. Data are evolving as to whether VA is preferentially oxidized for energy.46 

Saturated Fatty Acids Saturated fatty acids (SFAs) are made up of a carbon chain with no double bonds. Because fatty acids are cell-membrane structural units, this saturated configuration contributes to decreased cell-membrane fluidity. SFAs are not essential nutrients. They are mainly obtained through dietary intake of animal fats. However, the body is capable of synthesizing SFAs from carbohydrates via de novo lipogenesis. The synthesized SFAs are the same FAs found in dietary animal fats. Therefore reducing disease risk using dietary modification should also include carbohydrate reduction. Most saturated fatty acid studies focus solely on their tendency to alter lipoprotein metabolism and influence cholesterol levels. Additionally, several studies have demonstrated that